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.

胸腹腔镜食管癌根治术中人工气胸的应用效果分析

目的:探讨胸腹腔镜食管癌根治术中人工气胸的应用效果。方法:选取2016年8月至2023年3月行胸腹腔镜食管癌根治术的86例患者,将患者按随机数字表法分为对照组(n=43)与观察组(n=43),对照组行双腔管单肺通气,观察组行单腔管双肺通气联合人工气胸;比较两组手术时间、术中出血量、术后清醒时间、术后住院时间及人工气胸或单肺通气前(T_(1))、人工气胸或单肺通气30 min(T_(2))、人工气胸或单肺通气60 min(T_(3))、术后30 min(T4)的PaCO_(2)、PaO_(2)、平均动脉压及心率。结果:观察组术后住院时间短于对照组(P<0.05);T_(2)、T_(3)时,观察组PaCO_(2)水平高于T_(1)时;观察组高于对照组(P<0.05);T_(2)、T_(3)、T4时,两组PaO_(2)水平均低于T_(1)时,观察组高于对照组(P<0.05);T_(2)时,两组平均动脉压水平均高于T_(1)时,观察组高于对照组(P<0.05);T_(2)、T_(3)时,两组心率均高于T_(1)时,观察组高于对照组(P<0.05)。观察组术后并发症总发生率低于对照组[18.60%(8/43)vs.39.53%(17/43),P=0.033]。结论:胸腹腔镜食管癌根治术中应用人工气胸对术中呼吸、血流动力学均有影响,术后并发症更少,康复更快。

分期手术治疗食管恶性肿瘤70例临床分析

目的:探讨分期手术治疗食管恶性肿瘤的围手术期安全性和预后情况。方法:本研究为回顾性病例系列研究。回顾性分析上海交通大学医学院附属胸科医院胸外科2015年1月至2023年1月收治的接受食管恶性肿瘤分期手术的70例患者的临床资料。男性58例,女性12例,年龄[M(IQR)]61(22)岁(范围:9~79岁),65岁以上的比例为51.4%(36/70)。患者均接受一期手术切除食管肿瘤及二期手术完成消化道重建。总结分期手术原因,记录并发症及其处理结果。利用Kaplan-Meier曲线分析预后情况。结果:分期手术间隔时间为49(35)d(范围:32~82 d)。随访时间为28(50)个月(范围:1~69个月)。患者一期手术后30 d内病死率为4.3%(3/70),二期手术后30 d内病死率为0(0/63)。一期手术总体并发症发生率为55.7%(39/70),呼吸系统并发症发生率为10.0%(7/70),心血管系统并发症发生率为5.7%(4/70)。二期手术吻合口瘘发生率为11.1%(7/63)。患者术后2、3、5年的总体生存率分别为35.7%、30.0%、15.7%。结论:食管恶性肿瘤分期手术是可行的,效果较为满意。

胸腹联合腔镜下食管癌根治术后肺部并发症的危险因素分析及预测模型建立

目的:筛选胸腹联合腔镜下食管癌根治术术后肺部并发症(postoperative pulmonary complications,PPCs)发生的危险因素,建立PPCs列线图预测模型,为该类患者PPCs的早期识别和防治提供临床指导。方法:本研究回顾性收集2022年03月至2022年08月在南京医科大学附属淮安第一医院行胸腹联合腔镜下食管癌根治术患者的临床资料。根据术后7天内是否发生PPCs,将患者分为PPCs组与非PPCs组。运用SPSS 26.0软件行logistic单因素和多因素回归分析,筛选出PPCs的危险因素。运用R语言建立Nomogram预测模型;并绘制受试者工作特征(ROC)曲线、校准曲线以及临床决策(DCA)曲线分别评价模型的区分度、一致性和临床实用性。结果:本研究共纳入165例患者,发生PPCs 79例。逻辑回归分析显示:男性、肺年龄、术前PEF百分比、术前WBC、术后24 h血糖变异系数是胸腹联合腔镜下食管癌根治术发生PPCs的独立危险因素(P<0.05)。根据这些危险因素构建Nomogram列线图预测模型,ROC曲线下面积0.821,特异性73.3%,敏感性79.7%,校准曲线一致性良好,DCA决策曲线净收益良好。结论:男性、肺年龄、术前PEF百分比、术前WBC、术后24 h血糖变异系数是胸腹联合腔镜下食管癌根治术PPCs发生的独立危险因素。建立的Nomogram列线图模型具有较高的PPCs预测效能,能帮助早期识别PPCs高风险人群。

CD4^(+)/CD8^(+)、改良临床肺部感染评分、营养风险筛查评分与食管癌胸腔镜术后肺部感染关系及意义

目的 探讨CD4^(+)/CD8^(+)联合改良临床肺部感染(mCPIS)评分、营养风险筛查(NRS2002)评分预测食管癌胸腔镜术后肺部感染价值。方法 选取2020年12月至2021年10月衡水市第三人民医院与衡水市第二人民医院收治的120例行食管癌胸腔镜术病人进行前瞻性队列研究,根据术后住院期间是否发生肺部感染分为感染组、未感染组,采用logistic回归构建食管癌胸腔镜术后肺部感染状态的联合预测因子模型,并绘制受试者操作特征(ROC)曲线。结果 感染组CD4^(+)/CD8^(+)(0.78±0.14)低于未感染组(1.06±0.18)(P<0.05);感染组mCPIS评分、NRS2002评分分别为(3.49±1.13)分、(10.89±2.18)分高于未感染组的(1.02±0.28)分、(6.22±2.49)分(P<0.05);CD4^(+)/CD8^(+)、mCPIS、NRS2002评分均是影响感染发生的相关影响因素(P<0.05),生成联合预测因子模型表达式:logit(P)=-5.007-0.702×X_(1)+1.832×X_(2)+1.934×X_(3);ROC分析显示联合预测因子预测效能最高,联合预测因子最佳截断值为0.11,预测准确率为83.33%。结论 CD4^(+)/CD8^(+)、mCPIS、NRS2002评分均与食管癌胸腔镜术后肺部感染发生有关,基于三者生成的联合预测因子有望为临床预测术后肺部感染风险提供准确的参考信息。

基于倾向评分匹配的机器人辅助与胸腹腔镜微创三切口食管癌根治术近期疗效比较

【目的】探讨机器人辅助微创食管癌切除术(RAMIE)和胸腹腔镜联合微创食管癌切除术(MIE)的安全性与有效性。【方法】回顾性分析中国科学技术大学第一附属医院胸外科2021年4月至2022年12月收治的188例接受微创Mckeown食管癌切除术的患者资料。其中RAMIE组69例,男性49例,女性20例,年龄(67.2±7.2)岁;MIE组119例,男性89例,女性30例,年龄(69.1±7.0)岁。采用倾向性评分匹配法(PSM)对两组患者进行1∶1匹配,匹配后RAMIE组58例,MIE组58例。采用t检验、Pearsonχ^(2)检验、Fisher’s精确检验等比较两组患者术中情况和术后并发症发生率。【结果】经过PSM处理后,两组患者基线资料无明显差异。RAMIE组和MIE组在手术时间、术后带管天数、淋巴结清扫总数方面无明显差异(P<0.05);在术中出血、左喉返淋巴结清扫数目方面RAMIE组优于MIE组,差异有统计学意义(P<0.05);MIE组在淋巴结清扫总站数方面更优(P<0.05)。在术后并发症方面RAMIE组和MIE组两组数据差异无统计学意义(P>0.05)【结论】RAMIE近期疗效与MIE食管癌切除术相当;机器人辅助微创食管癌切除术可以减少术中出血同时在淋巴结清扫中尤其是在喉返神经旁淋巴结清扫中更具优势。

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.

影响食管癌胸腔镜食管切除术后肺部并发症的因素

目的探讨食管癌胸腔镜食管切除术后肺部并发症(PPC)的危险因素。方法回顾性收集2019年1月至2022年6月期间接受胸腔镜食管切除术的181例食管癌患者的临床病历资料。记录患者术后PPC发生情况。采用多因素Logistic回归模型分析影响PPC发生的因素,并构建列线图。结果术后46例患者发生PCC。PPC与年龄、ASA分级、吸烟史、COPD和术后谵妄均有关(P<0.05);与其他临床病理参数无关(P>0.05)。多因素Logistic回归分析结果显示年龄>60岁、ASA分级Ⅲ/Ⅳ级、COPD和术后谵妄是PPC发生风险的独立危险因素(P<0.05)。构建列线图预测模型显示C指数为0.67(95%CI:0.62~0.72)。结论术前COPD和术后谵妄是食管癌患者胸腔镜食管切除术PPC风险的独立危险因素,建议采取预防措施以降低食管癌患者食管切除术PPC的发生率。

食管癌患者选择不同手术方案对机体免疫功能及预后效果的影响

目的:分析食管癌患者临床治疗中采用不同手术方案的价值。方法:选取2019年10月—2021年8月样本医院收治的60例食管癌患者作为研究对象,按随机数表法分为对照组和观察组,每组各30例。对照组采用常规食管癌根治术治疗,观察组采用胸腔镜食管癌根治术治疗,对比两组患者并发症率、手术指标、免疫功能、满意度。结果:观察组并发症率低于对照组,差异有统计学意义(χ^(2)=4.812,P<0.05);观察组术中出血量、手术时间、住院时间、首次排气时间较对照组均降低,差异有统计学意义(t=24.763、5.206、15.148、7.611,P<0.05);治疗后,观察组CD4^(+)、NK高于对照组,差异有统计学意义(t=5.168、4.618,P<0.05);观察组满意度高于对照组,差异有统计学意义(χ^(2)=5.192,P<0.05)。结论:选择胸腔镜食管癌根治术对食管癌进行治疗可改善患者免疫功能,亦可降低术中出血量,提高患者满意度。

基于CT评估胸肌指数对胸腔镜食管癌根治术后短期预后的影响

目的探讨术前基于CT评估胸肌指数(PMI)对胸腔镜食管癌根治术后短期预后的影响。方法选择安徽省第二人民医院胸心外科2018年12月至2022年2月因食管癌接受胸腔镜根治性手术患者80例为研究对象,根据PMI得分中位数将患者分为高PMI组和低PMI组。患者在入院后48h内通过电子病历系统收集性别、年龄、体质量指数、肿瘤位置、TNM分期、白蛋白、淋巴细胞计数情况。统计患者无进展生存(PFS)和总生存(OS);术后7d内使用营养风险筛查评分2002(NRS2002)量表对患者营养风险进行筛查,统计患者住院时间、住院期间肺部感染情况。结果两组性别、年龄、体质量指数、肿瘤位置、TNM分期和淋巴细胞计数比较差异无统计学意义(P>0.05);低PMI组白蛋白低于高PMI组,差异具有统计学意义(P<0.05);80例患者共随访13~40个月,中位随访27个月,共16例死亡,其中高PMI组5例,低PMI组11例。高PMI组中位PFS、OS分别为23个月和29个月,低PMI组PFS、OS分别为15个月和24个月,两组比较差异具有统计学意义(χ^(2)=8.100、5.049,P=0.004、0.025);COX回归分析结果显示,矫正前后术前PMI均是食管癌患者短期预后的独立影响因素(P<0.05)。低PMI组营养风险、住院时间和肺部感染发生率高于高PMI组,比较差异有统计学意义(P<0.05)。结论低PMI的胸腔镜食管癌根治术患者术后短期病情进展和死亡风险较高、营养风险较高,住院时间较长,肺部感染发生率也较高。

国产手术机器人辅助下McKeown食管癌切除术:海南省首例报道(附手术视频)

海南医科大学第二附属医院胸外科于2024年5月21使用国产精锋®手术机器人系统完成颈胸腹三切口食管癌根治手术1例,整个手术过程耗时约320 min,其中机器人手术系统的对接时间大约为20 min,出血量50 mL,未见术后并发症发生。

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.

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.

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.

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.

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.

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.