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.

Learning curves in minimally invasive esophagectomy

Surgical innovation and pioneering are important for improving patient outcome, but can be associated with learning curves. Although learning curves in surgery are a recognized problem, the impact of surgical learning curves is increasing, due to increasing complexity of innovative surgical procedures, the rapid rate at which new interventions are implemented and a decrease in relative effectiveness of new interventions compared to old interventions. For minimally invasive esophagectomy(MIE), there is now robust evidence that implementation can lead to significant learning associated morbidity(morbidity during a learning curve, that could have been avoided if patients were operated by surgeons that have completed the learning curve). This article provides an overview of the evidence of the impact of learning curves after implementation of MIE. In addition, caveats for implementation and available evidence regarding factors that are important for safe implementation and safe pioneering of MIE are discussed.

Analysis of the relationship between deep venous catheter-related infection and post-operative complications in patients receiving minimally invasive esophagectomy

Objective The aim of the study was to evaluate catheter-related infection rate(CRIR)for patients receiving minimally invasive esophagectomy(MIE),to identify the optimal catheterization approach and relationship between CRIR and post-operative complications.Methods In total,168 patients with esophageal carcinoma and undergoing MIE combined with preoperative deep venous catheterization(DVC)were analyzed in our institution(Qingdao Municipal Hospital,China),from 2014 to 2018.After completing DVC,catheter-tips together with intraductal venous blood samples were sent to the microbiology lab for bacterial strain culture.CRIR was statistically evaluated for the following clinical variables:gender,age,smoking status,drinking status,past history,tumor location,histologic grade,pathological T,N,and M category,anastomotic location,anastomotic leakage,anastomotic stricture,chylothorax,pneumonia,recurrent laryngeal nerve(RLN)injury,reflux esophagitis,catheterization site,and catheter-locking days.Results Among the 144 patients recruited in our study,105 catheters were inserted into the jugular vein and 39 catheters into the subclavian vein.The median age of these patients was 63 years(range:42–79 years),and the median catheter-locking period was seven days(range:4–21 days).Four catheters were identified with three types of strain colonizations,including Staphylococcus epidermidis,Staphylococcus aureus and Blastomyces albicans.Statistical data showed that patients diagnosed with catheter-related infection were likely to incur anastomotic leakage(66.67%,P<0.001)and pneumonia(27.27%,P<0.001);features such as tumors located in the upper esophagus(13.6%,P=0.003),and over seven catheterlocking days(10.00%,P<0.001)were attributed to a high CRIR.Conclusion Although both jugular and subclavian veins can be catheterized for patients with MIE,DVC is associated with more than seven catheter-locking days and upper esophagectomy,due to high CRIR.Furthermore,catheter-related infection is related to anastomotic leakage and pneumonia.

Modified McKeown minimally invasive esophagectomy for esophageal cancer: A retrospective study of 376 patients at a single institution

Objective:Minimally invasive esophagectomy(MIE)was first implemented in 1992 and various MIEs have been performed subsequently.The modified McKeown MIE that includes thoracoscopic and laparoscopic procedures with left neck anastomosis has been implemented in our institution since 2006.We herein report our first 5-year experience in 376 consecutive patients undergone the modified McKeown MIE for esophageal cancer to evaluate perioperative outcomes and survival.Methods:A total of 376 patients underwent a modified McKeown MIE from March 2016 toMarch 2021 at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.Patient demographics and perioperative outcomes were collected and assessed,and overall survival and disease-free survival were analyzed.Results:All procedures were completed successfully with no conversions to open surgery.The median operative time was 240 min,and the median blood loss was 100 mL.The median number of harvested lymph nodes was 29,the median number of harvested thoracic lymph nodes was 18,and of harvested abdominal nodes was 10.The 30-day mortality rate was 0.27%and complications occurred in 133(35.4%)patients.The median follow-up period was 19(1-60)months,and 244 patients completed more than 1 year of follow-up.The 1-year overall survival and disease-free survival were 79.5%and 73.8%,respectively.Conclusion:The modified McKeown MIE is safe and feasible for esophageal cancer,offering satisfactory perioperative outcomes and acceptable oncologic survival.

Comparison of the surgical outcomes of McKeown minimally invasive esophagectomy and Ivor-Lewis esophagectomy for the treatment of middle esophageal cancer:A single-center retrospective study

Background:In China,the esophageal cancer is the most common tumor type,and the main treatment is still surgical treatment.Over the past decade,thoracic laparoscopy combined with esophageal cancer resection and neck anastomosis-McKeown minimally invasive esophagectomy(MIE)has gained interest and known as a minimally invasive surgery for the middle esophageal cancer.However,the safety and operability of McKeown MIE remains to be confirmed clinically.The purpose of this article is to examine the clinical safety and operability of McKeown MIE,and compare the security and outcomes of McKeown MIE and Ivor-Lewis esophagectomy.Materials and methods:The clinical data of 312 patients with middle esophageal cancer in Sir Run Run Shaw Hospital from January 2013 to December 2018 were retrospectively analyzed.Among them,176 patients underwent Ivor-Lewis esophagectomy and 136 patients underwent McKeown MIE.Patients'demographics and perioperative outcomes were comparable between the two groups.Results:There were no significant differences in terms of operative time,postoperative hospital stay,restore fluid diet time,pathology,tumor node metastasis staging between the two groups.In the McKeown MIE group,the intraoperative blood loss was less than that in the Ivor-Lewis group(116.54±80.99 ml vs 152.78±115.35 ml,p=0.001).The total number of lymph nodes and the number of lymph nodes dissection in bilateral recurrent laryngeal nerves were more than those in the Ivor-Lewis group(30.04±14.08 vs 27.51±11.34,p=0.039;5.74±4.27 vs 1.80±2.68,p<0.001).There were no significant differences in the incidence of complications.The overall survival for the McKeown MIE group was higher than the Ivor-Lewis group(p=0.013)and no significant difference was found on disease-free survival.Conclusion:McKeown MIE is safe and operational for middle esophageal cancer,which is consistent with the principle of tumor radicalization.

Minimally invasive esophagectomy for the treatment of esophageal cancer:a report of 81 cases

Objective To assess the feasibility and clinical efficacy of minimally invasive esophagectomy for esophageal cancer. Methods From July 2007 to December 2009,eighty-one patients with esophageal cancer received combined thoracoscopic and laparoscopic esophagectomy with anastomosis in the neck. All clinical data were retrospectively reviewed. Results The median operative

Prediction and stratification for the surgical adverse events after minimally invasive esophagectomy:A two-center retrospective study

BACKGROUND Minimally invasive esophagectomy(MIE)is a widely accepted treatment for esophageal cancer,yet it is associated with a significant risk of surgical adverse events(SAEs),which can compromise patient recovery and long-term survival.Accurate preoperative identification of high-risk patients is critical for improving outcomes.AIM To establish and validate a risk prediction and stratification model for the risk of SAEs in patients with MIE.METHODS This retrospective study included 747 patients who underwent MIE at two centers from January 2019 to February 2024.Patients were separated into a train set(n=549)and a validation set(n=198).After screening by least absolute shrinkage and selection operator regression,multivariate logistic regression analyzed clinical and intraoperative variables to identify independent risk factors for SAEs.A risk stratification model was constructed and validated to predict the probability of SAEs.RESULTS SAEs occurred in 10.2%of patients in train set and 13.6%in the validation set.Patients with SAE had significantly higher complication rate and a longer hospital stay after surgery.The key independent risk factors identified included chronic obstructive pulmonary disease,a history of alcohol consumption,low forced expiratory volume in the first second,and low albumin levels.The stratification model has excellent prediction accuracy,with an area under the curve of 0.889 for the training set and an area under the curve of 0.793 for the validation set.CONCLUSION The developed risk stratification model effectively predicts the risk of SAEs in patients undergoing MIE,facilitating targeted preoperative interventions and improving perioperative management.

Minimally invasive versus open esophagectomy for resectable thoracic esophageal cancer(NST 1502):a multicenter prospective cohort study

Background:Whether minimally invasive esophagectomy(MIE)is superior to open esophagectomy(OE)in the treatment of esophageal squamous cell carcinoma(ESCC)is still uncertain.Therefore,this multicenter prospective study aimed to compare MIE with OE in postoperative parameters and long-term survival.Methods:All hospitalized patients with cT1b-3N0-1M0 thoracic ESCC treated by MIE or OE were enrolled from 19 selected centers from April 1,2015 to December 31,2018.The propensity score matching(PSM)was performed to minimize the selection bias.The basic clinicopathological characteristics and 3-year overall survival(OS)as well as disease-free survival(DFS)of two groups were compared by R version 3.6.2.Results:MIE were performed in 1,387 patients and OE in 335 patients.335 cases in each group were finally matched by PSM,and no significant differences in the essential demographic characteristics were observed be-tween the MIE and OE groups after PSM.Compared with OE,MIE had significantly less intraoperative bleeding,less total drainage volume,shorter postoperative hospital stay,and harvested significantly more lymph nodes(LNs)(all P<0.001).There were no significant differences in the major postoperative complications and death rates between MIE and OE.The 3-year OS and DFS were 77.0%and 68.1%in the MIE group versus 69.3%and 60.9%in the OE group(OS:P=0.03;DFS:P=0.09),and the rates were 75.1%and 66.5%in the MIE group versus 66.9%and 58.6%in the OE group for stage cII patients(OS:P=0.04,DFS:P=0.09),respectively.Conclusions:Compared with OE,MIE is a safe and effective treatment approach with similar mortality and morbidity.It has the advantages in harvesting more LNs,improving postoperative recovery and survival of stage cII ESCC patients.

Comparisons of minimally invasive esophagectomy and open esophagectomy in lymph node metastasis/dissection for thoracic esophageal cancer

Background:The study aimed to clarify the characteristics of lymph node metastasis(LNM)and to compare the oncologic outcomes of minimally invasive esophagectomy(MIE)with open esophagectomy(OE)in terms of lymph node dissection(LND)in thoracic esophageal cancer patients.Methods:The data from esophageal cancer patients who underwent MIE or OE from January 2016 to January 2019 were retrospectively reviewed.The characteristics of LNM in thoracic esophageal cancer were discussed,and the differences in numbers of LND,LND rate,and LNM rate/degree of upper mediastinum between MIE and OE were compared.Results:For overall characteristics of LNM in 249 included patients,the highest rate of LNM was found in upper mediastinum,while LNM rate in middle and lower mediastinum,and abdomen increased with the tumor site moving down.The patients were divided into MIE(n=204)and OE groups(n=45).In terms of number of LND,there were significant differences in upper mediastinum between MIE and OE groups(8[5,11]vs.5[3,8],P<0.001).The comparative analysis of regional lymph node showed there was no significant difference except the subgroup of upper mediastinal 2L and 4L group(3[1,5]vs.0[0,2],P<0.001 and 0[0,2]vs.0,P=0.012,respectively).Meanwhile,there was no significant difference in terms of LND rate except 2L(89.7%[183/204]vs.71.1%[32/45],P=0.001)and 4L(41.2%[84/204]vs.22.2%[10/45],P=0.018)groups.For LNM rate of T3 stage,there was no significant difference between MIE and OE groups,and the comparative analysis of regional lymph node showed that there was no significant difference except 2L group(11.1%[5/45]vs.38.1%[8/21],P=0.025).The LNM degree of OE group was significantly higher than that of MIE group(27.2%[47/173]vs.7.6%[32/419],P<0.001),and the comparative analysis of regional LNM degree showed that there was no significant difference except 2L(34.7%[17/49]vs.7.7%[13/169],P<0.001)and 4L(23.8%[5/21]vs.3.9%[2/51],P=0.031)subgroups.Conclusion:MIE may have an advantage in LND of upper mediastinum 2L and 4L groups,while it was similar to OE in other stations of LND.

Gastrointestinal function testing model using a new laryngopharyngeal pH probe(Restech)in patients after Ivor-Lewis esophagectomy

BACKGROUND There is no established correlation between 24-h esophageal pH-metry(Eso-pH)and the new laryngopharyngeal pH-monitoring system(Restech)as only small case series exist.Eso-pH was not designed to detect laryngopharyngeal reflux(LPR)and Restech may detect LPR better.We have previously published a dataset using the two techniques in a large patient collective with gastroesophageal reflux disease.Anatomically,patients after esophagectomy were reported to represent an ideal human reflux model as no reflux barrier exists.AIM To use a human reflux model to examine our previously published correlation in these patients.METHODS Patients after Ivor Lewis esophagectomy underwent our routine follow-up program with surveillance endoscopies,computed tomography scans and further exams following surgery.Only patients with a complete check-up program and reflux symptoms were offered inclusion into this prospective study and evaluated using Restech and simultaneous Eso-pH.Subsequently,the relationship between the two techniques was evaluated RESULTS A total of 43 patients from May 2016-November 2018 were included.All patients presented with mainly typical reflux symptoms such as heartburn(74%),regurgitation(84%),chest pain(58%),and dysphagia(47%).Extraesophageal symptoms such as cough,hoarseness,asthma symptoms,and globus sensation were also present.Esophageal 24-hour pH-metry was abnormal in 88%of patients with a mean DeMeester Score of 229.45[range 26.4-319.5].Restech evaluation was abnormal in 61%of cases in this highly selective patient cohort.All patients with abnormal supine LPR were also abnormal for supine esophageal reflux measured by conventional Eso-pH.CONCLUSION Patients following esophagectomy and reconstruction with gastric interposition can ideally serve as a human reflux model.Interestingly,laryngopharyngeal reflux phases occur mainly in the upright position.In this human volume-reflux model,results of simultaneous esophageal and laryngopharyngeal(Restech)pHmetry showed 100%correlation as being explicable by one of our reflux scenarios.

Short Term Operative Outcomes of Laparoscopic Gastric Mobilization in Esophagectomy for Esophageal Cancer: Comparison with Hand Assisted Technique

Objective: This study evaluated the safety and operative utilities of the laparoscopic gastric mobilization compared with hand-assisted laparoscopic gastric mobilization. Patients and Methods: From April 2010 to November 2015, 125 patients with esophageal cancer have been performed laparoscopic mobilization;33 under hand-assisted laparoscopic gastric mobilization (HLG group) and 92 under laparoscopic gastric mobilization without hand-assisted technique (LG group). Preoperative data and surgical outcomes of 2 groups were compared. Results: Preoperative data were not significantly different except for BMI. Operation time in abdominal procedure of LG group is significantly longer than HLG group (P < 0.0001). Otherwise, the blood loss and number of dissected nodes of abdominal procedure was not significantly different in two groups. The perioperative blood transfusions were needed in 7 cases (21.2%) in HLG group and 25 (27.1%) in LG group. The postoperative complications and mortality within 30 days after surgery were not significantly different in two groups. The length of hospital stay was 29 days in HLG group and 31 days in HG group, respectively. Conclusions: Our results suggested that laparoscopic gastric mobilization was safe technique and the short-term operative outcomes were comparable with that of hand-assisted laparoscopic mobilization.

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.

Efficacy and prognostic analysis of carbon nanotracers combined with the da Vinci robot in the treatment of esophageal cancer

BACKGROUND Traditional methods cannot clearly visualize esophageal cancer(EC)tumor contours and metastases,which limits the clinical application of da Vinci robotassisted surgery.AIM To investigate the efficacy of the da Vinci robot in combination with nanocarbon lymph node tracers in radical surgery of EC.METHODS In total,104 patients with early-stage EC who were admitted to Liuzhou worker's Hospital from January 2020 to June 2023 were enrolled.The patients were assigned to an observation group(n=52),which underwent da Vinci robot-assisted minimally invasive esophagectomy(RAMIE)with the intraoperative use of nanocarbon tracers,and a control group(n=52),which underwent traditional surgery treatment.The operation time,intraoperative blood loss,postoperative drainage tube indwelling time,hospital stay,number of lymph nodes dissected,incidence of complications,and long-term curative effects were comparatively analyzed.The postoperative stress response C-reactive protein(CRP),cortisol,epinephrine(E)and inflammatory response interleukin(IL)-6,IL-8,IL-10,and tumor necrosis factor-alpha(TNF-α)were evaluated.RESULTS Compared with the control group,the observation group had significantly lower postoperative CRP,cortisol,and E levels(P<0.05)with a milder inflammatory response,as indicated by lower IL-6,IL-10,and TNF-αlevels(P<0.05).Patients who underwent RAMIE had less intraoperative blood loss and shorter operation times and hospital stays than those who underwent traditional surgery.The average number of dissected lymph nodes,time of lymph node dissection,and mean smallest lymph node diameter were all significantly lower in the observation group(P<0.05).The rate of postoperative complications was 5.77%in the observation group,significantly lower than the 15.38%observed in the control group.Furthermore,the lymphatic metastasis rate,reoperation rate,and 12-and 24-month cumulative mortality in the observation group were 1.92%,0%,0%,and 0%,respectively,all of which were significantly lower than those in the control group(P<0.05).CONCLUSION The treatment of EC using the da Vinci robot combined with nanocarbon lymph node tracers can achieve good surgical outcomes and demonstrates promising clinical applications.

Clinical analysis of minimally invasive McKeown esophagectomy in a single center by a single medical group

Objective： McKeown esophagectomy followed by cervical and abdominal procedures has been commonly used for invasive esophageal carcinoma. This minimally-invasive operative procedure in the lateral prone position has been considered to be the most appropriate method. We describe our experiences in minimally invasive McKeown esophagectomy （MIME） for esophageal cancer. Methods： Between March 2016 and February 2018, a total of 82 patients underwent MIME by a single group in our department （a single center）. All procedure, operation, oncology, and complication data were reviewed. Results： All MIME procedures were completed successfully, with no conversions to open surgery. The median operative time was 260 min, and median blood loss was 100 ml. The average number of total harvested lymph nodes was 20.1 in the chest and 13.5 in the abdomen. There were no deaths within 30 postoperative days. Twenty cases （24.4%） developed postoperative complications, including anastomotic leak in 4 （4.9%）, single lateral recurrent nerve palsy in 4 （4.9%）, bilateral recurrent nerve palsy in 1 （1.2%）, pulmonary problems in 3 （3.7%）, chyle ~eak in 1 （1.2%）, and other complications in 7 （including pleural effusions in 4, incomplete ileus in 2, and neck incision infection in 1; 8.54%）. Average postoperative hospitalization time was 12 d. Blood loss, operation time, morbidity rate, and the number of harvested lymph nodes were analyzed by evaluating learning curves in different periods. Significant differences were found in operative time （P=-0.006）, postoperative hospitalization days （P=0.015）, total harvested lymph nodes （P=0.003）, harvested thoracic lymph nodes （P=0.006）, and harvested abdominal lymph nodes （P=0.022） among different periods. Conclusions： Surgical outcomes following MIME for esophageal cancer are safe and acceptable. The MIME procedure for stages I and II could be performed proficiently and reached an experience plateau after approximately 25 cases.

Applications and prospects of robotic surgery in esophageal cancer

Esophageal cancer(EC)is among the most common malignances and one of the leading causes of cancer-related death worldwide.Surgery plays a significant role in the multidisciplinary treatment for esophageal cancer.Recent advances in minimally invasive esophagectomy(MIE),including conventional thoracoscopic surgery and more recent robotic surgery,has been shown to improve short-term outcomes compared to open surgery.Robot-assisted minimally invasive esophagectomy(RAMIE)was first performed in 2003 and has been increasingly utilized in tertiary medical centers.Compared to conventional video-assisted minimally esophagectomy(VAMIE),RAMIE provides certain advantages such as increased magnification,three-dimensional visual clarity and better lymphadenectomy,with superior short-term outcome and at least equivalent oncological results.This review focuses on the techniques,benefits and obstacles in applications of robotic esophagectomy for treating EC,meanwhile discussing the future of robotic esophageal surgery.

Current status of esophageal cancer treatment

Esophageal cancer(EC) remains one of the most common and aggressive diseases worldwide.This review discusses some debates in the modern management of the disease.Endoscopic procedures for early cancer(T1a-b) are now embedded in routine care and the challenge will be to more accurately select patients for endoscopic resection with or without adjuvant therapy.Perioperative multimodal therapies are associated with improved survival compared to surgery alone for locally advanced esophageal cancer.However, there is no global consensus on the optimal regimen.Furthermore, histological subtype(adenocarcinoma vs.squamous cell cancer) plays a role in the choice for treatment.New studies are underway to resolve some issues.The extent of the lymphadenectomy during esophagectomy remains controversial especially after neoadjuvant chemoradiation.The ideal operation balances between limiting surgical trauma and optimizing survival.Minimally invasive esophagectomy and enhanced recovery pathways are associated with decreased morbidity and faster recovery albeit there is no consensus yet what approach should be used.Finally, immune checkpoint inhibitors present promising preliminary results in the novel treatment of advanced or metastatic EC but their widespread application in clinical practice is still awaited.

Outcomes of curative esophageal cancer surgery in elderly:A metaanalysis

BACKGROUND An increasing number of older patients is undergoing curative,surgical treatment of esophageal cancer.Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients,which may lead to patient selection based on age.However,only studies including patients that underwent open esophagectomy were included.Therefore,it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.AIM To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.METHODS Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included.Meta-analysis of studies using a 75-year age threshold are presented in the manuscript,studies using other age thresholds in the Supplementary material.MEDLINE,Embase and the Cochrane Library were searched for articles published between 1995 and 2020.Risk of bias was assessed with the Newcastle-Ottawa Scale.Primary outcomes were anastomotic leak,pulmonary and cardiac complications,delirium,30-and 90-d,and in-hospital mortality.Secondary outcomes included pneumonia and 5-year overall survival.RESULTS Seven studies(4847 patients)using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients.Older patients(9.05%)had higher rates of 90-d mortality compared with younger patients(3.92%),(confidence interval=1.10-5.56).In addition,older patients(9.45%)had higher rates of in-hospital mortality compared with younger patients(3.68%),(confidence interval=1.01-5.91).In the subgroup of 2 studies with minimally invasive esophagectomy,older and younger patients had comparable 30-d,90-d and in-hospital mortality rates.CONCLUSION Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk.Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Perioperative toripalimab plus neoadjuvant chemotherapy might improve outcomes in resectable esophageal cancer:an interim analysis of a phase Ⅲ randomized clinical trial

Background:In the era of immunotherapy,neoadjuvant immunochemotherapy(NAIC)for the treatment of locally advanced esophageal squamous cell carcinoma(ESCC)is used clinically but lacks of high-level clinical evidence.This study aimed to compare the safety and long-term efficacy of NAIC followed byminimally invasive esophagectomy(MIE)with those of neoadjuvant chemotherapy(NAC)followed by MIE.Methods:A prospective,single-center,open-label,randomized phase Ⅲ clinical trial was conducted at Henan Cancer Hospital,Zhengzhou,China.Patients were randomly assigned to receive either neoadjuvant toripalimab(240mg)plus paclitaxel(175 mg/m^(2))+cisplatin(75 mg/m^(2))(toripalimab group)or paclitaxel+cisplatin alone(chemotherapy group)every 3 weeks for 2 cycles.After surgery,the toripalimab group received toripalimab(240 mg every 3 weeks for up to 6 months).The primary endpoint was event-free survival(EFS).The pathological complete response(pCR)and overall survival(OS)were key secondary endpoints.Adverse events(AEs)and quality of life were also assessed.Results:Between May 15,2020 and August 13,2021,252 ESCC patients ranging fromT1N1-3M0 to T2-3N0-3M0were enrolled for interim analysis,with 127 in the toripalimab group and 125 in the chemotherapy group.The 1-year EFS rate was 77.9%in the toripalimab group compared to 64.3%in the chemotherapy group(hazard ratio[HR]=0.62;95%confidence interval[CI]=0.39 to 1.00;P=0.05).The 1-year OS rates were 94.1%and 83.0%in the toripalimab and chemotherapy groups,respectively(HR=0.48;95%CI=0.24 to 0.97;P=0.037).The patients in the toripalimab group had a higher pCR rate(18.6%vs.4.6%;P=0.001).The rates of postoperative Clavien-Dindo grade Ⅲb or higher morbidity were 9.8%in the toripalimab group and 6.8%in the chemotherapy group,with no significant difference observed(P=0.460).The rates of grade 3 or 4 treatment-related AEs did not differ between the two groups(12.5%versus 12.4%).Conclusions:The interim results of this ongoing trial showed that in resectable ESCC,the addition of perioperative toripalimab to NAC is safe,may improve OS and might change the standard treatment in the future.

Long-term survival of esophageal squamous cell carcinoma after surgical treatment in a large-scale retrospective study from a single cancer center

Purpose To analyze the long-term overall survival(OS)and influencing factors of patients with esophageal squamous cell cancer(ESCC)under surgical treatment.Method We collected patients with ESCC who received surgical treatment in Sichuan Cancer Hospital&institute from January 2010 to December 2017,and selected 2,766 patients with thoracic esophageal carcinoma with relatively complete follow-up results as the objects of this study.We analyzed the characteristics,postoperative complications and long-term OS results of those patients.Results Of the 2766 patients,81.6%were male,midthoracic esophageal cancer accounted for 53.5%.McKeown was used in 72.0%of patients and Ivor-Lewis was used in 26.4%of patients.About 47.8%of patients received minimally invasive esophagectomy(MIE).The overall complication rate was 25.8%.The 1-year,3-year and 5-year OS rates were 86.2%,57.5%and 46.8%,respectively.McKeown had a better long-term OS rate than Ivor-Lewis(49.5%vs 41.2%,P<0.001),and MIE is superior to open surgery(51.8%vs 42.5%,P<0.001).Conclusion McKeown has advantages over Ivor-Lewis.MIE results in better long-term survival outcomes for patients.But more prospective randomized controlled trials with large samples are needed.

A case-control study on early removal of thoracic drainage tube and gastric tube after MIE

Objective To investigate the feasibility and safety of early removal of gastric tube and thoracic drainage tube after minimally invasive esophagectomy.Methods A retrospective analysis was performed on 93 patients undergoing thoraco-laparoscopic assisted esophagectomy between January 2022 and September 2022.All patients were divided into two groups,the early group and the conventional group.The differences in drainage volume on the first day after operation,days of thoracic drainage tube indwelling,thoracic drainage tube replacement,incidence rate of pleural effusion,atelectasis,pneumothorax as well as pulmonary infection,respiratory insufficiency,and postoperative hospital stay were compared between the two groups.The criteria for thoracic drainage tube removal is the daily thoracic drainage volume of less than 250 ml in the early group.The gastric fluid volume on the first day after operation,the number of days of gastric tube indwelling,the rate of gastric tube replacement after removal,and the time of intestinal exhaust were compared between the two groups.In the meantime,the incidence of complications,such as anastomotic leakage and pulmonary infection,was observed in the two groups.Results The removal time of gastric tube and thoracic drainage tube was significantly earlier in the early group than in the control group(P<0.05).There was no significant difference in the gastric fluid volume and pleural fluid between the early group and the conventional group(P>0.05),but there were significant differences in postoperative anastomotic leakage between the two groups(P<0.05).There was no significant difference in the incidence of pleural effusion,atelectasis,pneumothorax,and pulmonary infection(P>0.05),nor in thoracentesis rate and gastric tube replacement(P>0.05).The postoperative hospital stay was significantly shorter in the early group than in the conventional group(P<0.05)Conclusion The early removal of the thoracic drainge tube and gastric tube is safe and effective,which does not increase the incidence of postoperative complications.