Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for squamous cell carcinoma of the lower thoracic esophagus

AIM: To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS: From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS: The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients (71.2%). Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 (17.8%), 15 (20.5%), 30 (41.1%), and 25 (34.2%) patients, respectively. Postoperative staging was as follows: stageⅠin 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For N0 and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively (χ2 = 22.65, P < 0.01). The 5-year survival rate for patients in stages Ⅱa, Ⅱb and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively (χ2 = 29.18, P < 0.01). CONCLUSION: Ivor Lewis subtotal esophagectomywith two-field (total mediastinum) lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.

盆腔和低位腹主动脉旁淋巴结清扫对国际妇产科联盟分期Ⅰ期子宫内膜样癌患者的安全性和预后的影响

目的探讨盆腔和低位腹主动脉旁淋巴结清扫术对国际妇产科联盟(FIGO)分期Ⅰ期子宫内膜样癌患者疗效及预后的影响。方法回顾性分析2018年1月至2020年1月中国人民解放军联勤保障部队第910医院收治的81例接受手术治疗的早期子宫内膜样癌患者的临床资料。根据患者淋巴结清扫方法不同分为盆腔淋巴结清扫(PLD)组(n=44)和低位腹主动脉旁淋巴结清扫(PALD)+PLD组(n=37)。比较两组的手术相关资料、术后1年复发率、3年总生存率及并发症发生情况。结果PALD+PLD组的手术时间显著长于PLD组,淋巴结清扫数和阳性淋巴结数显著大于PLD组(P<0.05)。两组术中、术后并发症发生率比较,差异无统计学意义(P>0.05)。两组1年内复发率比较,差异具有统计学意义(P<0.05)。两组3年总生存率比较,差异无统计学意义(P>0.05)。结论盆腔和低位腹主动脉旁淋巴结清扫术可降低FIGO分期Ⅰ期子宫内样膜癌患者的复发率,且不会提高手术并发症发生率。

SiewertⅡ型食管胃结合部腺癌的外科治疗

外科手术是SiewertⅡ型食管胃结合部腺癌的主要治疗方式,但该部位的肿瘤具有独特的解剖结构及生物学特征,导致其淋巴转移途径、肿瘤浸润范围等较复杂,为其手术方式、切除范围及消化道重建等带来挑战与争议。本文将围绕以上几点,基于现有的循证医学证据,结合自身临床经验及前期研究结果,探讨目前SiewertⅡ型食管胃结合部腺癌外科的治疗策略。

全胸腔镜下肺叶切除术与开胸手术治疗非小细胞肺癌的疗效及对血清癌胚抗原、胸苷激酶1、血气指标的影响

目的 探讨全胸腔镜下肺叶切除术与小切口开胸肺叶切除术治疗非小细胞肺癌的临床效果,以及对血清癌胚抗原(CEA)、胸苷激酶1(TK1)和血气指标的影响。方法 纳入湖南医药学院总医院2017年4月至2019年3月收治的96例经病理检测诊断为非小细胞肺癌的患者,随机分为对照组与观察组,每组48例。观察组予全胸腔镜下肺叶切除术,对照组予开胸肺叶切除术,2组均予纵隔淋巴结清扫。比较2组患者围手术期指标及术后并发症发生率。分别于术前、术后采集患者静脉血,取血清后测定肿瘤坏死因子-α(TNF-α)、降钙素原(PCT)、超敏C反应蛋白(hs-CRP)、CEA、TK1水平。比较术前、术后2组患者视觉模拟评分(VAS)及血气指标。随访24个月,记录2组患者在此期间的生存情况。结果 观察组手术时间、下床活动时间及住院时间均短于对照组,术中出血量少于对照组(P<0.05);2组患者清扫淋巴结数量相当(P>0.05)。术后2组患者血清PCT、hs-CRP、TNF-α水平均升高,观察组低于对照组(P均<0.05)。术后2组患者血氧分压(PaO_(2))、二氧化碳分压(PaCO_(2))、剩余碱(BE)水平均降低;组间相比,观察组PaO_(2)水平高于对照组(P<0.05)。术后2组患者血清CEA、TK1水平均降低(P均<0.05),组间相比差异无统计学意义(P>0.05)。术前2组患者VAS评分相当,术后1 d、3 d、7 d观察组均低于对照组(P<0.05)。观察组术后并发症发生率低于对照组(6.25%vs 22.92%,P<0.05)。随访24个月,2组患者生存率比较差异无统计学意义(P>0.05)。结论 全胸腔镜下肺叶切除术可有效减轻术后疼痛并降低对肺功能的损伤,缩短住院时间,减少并发症发生率,在疗效上与小切口开胸手术相当,兼具高效性与安全性,值得临床推广使用。

机器人辅助腹腔镜手术治疗外阴癌中国专家共识(2024版):附视频

外阴癌的主要手术方式包括根治性外阴切除术/广泛局部切除+腹股沟淋巴结切除术。开放手术创伤大,术后并发症发生率高。机器人辅助腹腔镜下腹股沟淋巴切除术安全有效,且具有操作便捷、术后并发症发生率低、住院时间短等优势,但机器人辅助手术对术者要求高,需要妇科医生既掌握机器人手术专业知识,又具备腹股沟淋巴结清扫术技能,这样才能保证疗效,提高患者生存率。

改良肠系膜上动脉入路完全腹腔镜右半结肠癌根治术

目的探讨改良肠系膜上动脉(superior mesenteric artery,SMA)入路完全腹腔镜右半结肠癌完整结肠系膜切除(complete mesocolic excision,CME)、D3根治术的安全性和可行性。方法回顾性分析2021年4月~2023年4月完全腹腔镜右半结肠癌根治术77例临床资料。2022年8月前42例行传统SMA入路(对照组,仅以回结肠血管蒂为SMA尾侧标识),2022年8月后35例行改良SMA入路(改良组,以屈氏韧带和回结肠血管蒂分别为SMA的头、尾侧标识)。2组一般资料差异无统计学意义(P>0.05)。比较2组术中情况、术后恢复及术后并发症情况。结果与对照组相比,改良组手术时间短[(147.3±35.8)min vs.(173.4±29.9)min,t=-3.428,P=0.001],2组淋巴结清扫数目、阳性淋巴结数目、引流量、排气时间、术后住院时间及并发症发生率均无显著性差异(P>0.05)。结论改良SMA入路行完全腹腔镜右半结肠癌根治术可缩短手术时间,降低手术难度和风险,安全性和可行性更高。

Anatomy and influence of the splenic artery in laparoscopic spleen-preserving splenic lymphadenectomy

AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.

Prognostic impact of D2-plus lymphadenectomy and optimal extent of lymphadenectomy in advanced gastric antral carcinoma: Propensity score matching analysis

Objective: To investigate the prognostic impact of D2-plus lymphadenectomy including the posterior(No. 8 p,No. 12 b/p, No. 13, and No. 14 v), and para-aortic(No. 16 a2, and No. 16 b1) lymph nodes(LNs) in subtotal gastrectomy for advanced gastric antral carcinoma.Methods: A total of 203 patients with advanced gastric cancer(GC) located in the antrum, who underwent R0 gastrectomy with D2 or D2-plus lymphadenectomy between January 2003 and December 2011 were enrolled.Propensity score matching was used to reduce the strength of the confounding factors to accurately evaluate prognoses. The therapeutic value index(TVI) was calculate to evaluate the survival benefit of dissecting each LN station.Results: Of 102 patients with D2-plus lymphadenectomy, 21(20.59%) were pathologically identified as having LN metastases beyond the extent of D2 lymphadenectomy. After matching, the overall survival(OS) was significantly better in the D2-plus than the D2 group(P=0.030). In the multivariate survival analysis, D2-plus lymphadenectomy(hazard ratio, 0.516;P=0.006) was confirmed to significantly improve the survival rate. In the logistic regression analysis, p N stage [odds ratio(OR), 2.533;95% confidence interval(95% CI), 1.368-4.691;P=0.003] and extent of LNs metastasis(OR, 5.965;95% CI, 1.335-26.650;P=0.019) were identified as independent risk factors for LN metastases beyond the extent of D2 lymphadenectomy. The TVI of patient with metastasis to LNs station was 7.1(No. 8p), 5.7(No. 12p), 5.1(No. 13), and 7.1(both No. 16a2 and No. 16b1), respectively.Conclusions: D2-plus lymphadenectomy may improve the prognoses of some patients with advanced GC located in the antrum, especially for No. 8p, No. 12b, No. 13, and No. 16.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction （AEGs） have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.

Lymphatic spreading and lymphadenectomy for esophageal carcinoma

Esophageal carcinoma(EC) is a highly lethal malignancywith a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.

Evaluation of rational extent lymphadenectomy for local advanced gastric cancer

Based upon studies from randomized clinical trials, the extended （D2） lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes （PAN） in JCOG9501, the clinical benefit of D2＋ para-aortic nodal dissection （PAND） for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.l I nodes has been controversial, and however, the final results from the randomized trial ofJCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as MI stage in the current version of the Japanese classification. We propose that D2~No.14v and ＋No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Clinical significance of lymphadenectomy in patients with gastric cancer

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections,it was found that there is a significant difference in morbidity,favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy,and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However,the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized,stageadapted gastric cancer surgery the Maruyama computer program(MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival,than D-level guided surgery. For these reasons,the preoperative application of MCP is recommended routinely,with an aim to perform "low Maruyama Index surgery". The sentinel lymph node biopsy(SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate(93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.

Does an extended mediastinal lymphadenectomy improve outcome after R0 resection in lung cancer?

Objective： This retrospective study was conducted to investigate the impact of more extended mediastinal lymphadenectomy on the outcome of lung cancer patients treated with R0 resection. Methods： During the investigation period, 325 lung cancer cases were enlisted and 278 cases entered the analysis. The patients were divided into Control group （n=116） and Research group （n=162） according to the different extents of mediastinal lymph node clearance at different time periods. Three major parameters were retrospectively assessed to compare the quality of surgical care： extent of lymph node clearance, resection volume, and postoperative recovery process and common complications. Comparison of the outcome between two groups was carried out. Results： Research group showed a significant quality improvement of lymphadenectomy, such as more mediastinal node stations investigated （more than 3 N2 stations investigated： Research group, 90.7% vs. Control group, 55.2%; P=0.001） and more nodes collection （total nodes 26.1±10.0 vs. 19.1±8.3, P=0.000; N2 nodes 15.5±7.2 vs. 9.8±5.6, P=0.000）. However, overall survival （OS） and disease-free survival （DFS） were not significantly different either between two groups （5-year OS： Control group, 56.4±4.6% vs. Research group, 62.6±4.3%; P=0.271） or between subgroups from stage I to IIIa. TNM stage and histology were significant factors associated with OS and DFS in multivariate analysis; extent of mediastinal lymphadenectomy was not associated with OS or DFS. Conclusions： More radical mediastinal lymphadenectomy may not lead to an improved oncological outcome for lung cancer treated with R0 resection.

Therapeutic role of template-based lymphadenectomy in urothelial carcinoma of the upper urinary tract

Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional nodes for tumors of the right renal pelvis or the right upper two-thirds of the ureter. A prospective study showed that an anatomical templatebased lymphadenectomy significantly improved patient survival in tumors of the renal pelvis. This benefit was more evident for patients with p T2 stage tumors or higher. The risk of regional node recurrence is significant reduced by template-based lymphadenectomy,which is likely to be associated with improved patient survival. The removal of lymph node micrometastases is assumed to be the reason for therapeutic benefit following lymphadenectomy. The number of resected lymph nodes can be used to assess the quality of lymphadenectomy,but not to determine the extent of lymphadenectomy. The guidelines currently recommend lymphadenectomy for patients with muscle-invasive disease,even though the current recommendation grades are still low. The present limitation of lymphadenectomy is the lack of standardization of the extent of lymphadenectomy and the randomized trials. Further studies are warranted to collect the evidence to support lymphadenectomy.

Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer:Two distinct principles

Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation(CRT) followed by TME has been established as a standard treatment for decreasing local recurrence.Recently,several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan.A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone.Considering that almost 45 survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes(LLNs),EPL performed by experienced surgeons definitely contributes to decrease local recurrence.On the other hand,a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT.On this point,preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs.For future treatment,it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis.Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups,further studies would lead to the next great step towards future improvement in treating lower rectal cancer.

Systematic review of D2 lymphadenectomy versus D2 with para-aortic nodal dissection for advanced gastric cancer

AIM:To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.METHODS:Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a predefined search strategy.Five-year overall survival rate,post-operative mortality,and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.RESULTS:Four RCTs (1120 patients) and 4 nonrandomized studies (901 patients) were identif ied.Metaanalysis showed that there was no signif icant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI:0.93-1.16) for RCTs and 0.96 (95% CI:0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI:0.44-2.24) for RCTs and 2.06 (95% CI:0.69-6.15) for non-randomized studies].There was a significant difference between these two groups in wound degree of surgery,operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI:114.59-276.05) for RCTs and 126.07 min (95% CI:22.09-230.04) for non-randomized studies] and blood loss was signif icantly greater [WMD 301 mL (95% CI:151.55-450.45) for RCTs and 302.86 mL (95% CI:127.89-477.84) for non-randomized studies] in D2 + PAND.CONCLUSION:D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.

Extent of lymphadenectomy has no impact on postoperative complications after gastric cancer surgery in Sweden

Objective： Curative gastric cancer surgery entails removal of the primary tumor with adequate margins including regional lymph nodes. European randomized controlled trials with recruitment in the 1990＇s reported increased morbidity and mortality for D2 compared to D 1. Here, we examined the extent of lymphadenectomy during gastric cancer surgery and the associated risk for postoperative complications and mortality using the strengths of a population-based study. Methods： A prospective nationwide study conducted within the National Register of Esophageal and Gastric Cancer. All patients in Sweden from 2006 to 2013 who underwent gastric cancer resections with curative intent were included. Patients were categorized into DO, D I, or D I ＋/D2, and analyzed regarding postoperative morbidity and mortality using multivariable logistic regression. Results： In total, 349 （31.7%） patients had a DO, 494 （44.9%） DI, and 258 （23.4%） DI＋/D2 lymphadenectomy. The 30-d postoperative complication rates were 25.5%, 25.1% and 32.2 % （DO, D I and D1 ＋/D2, respectively）, and 90-d mortality rates were 8.3%, 4.3 % and 5.8%. After adjustment for confounders, in mukivariable analysis, there were no significant differences in risk for postoperative complications between the lymphadenectomy groups. For 90-d mortality, there was a lower risk for D1 vs. DO. Conclusions： The majority of gastric cancer resections in Sweden have included only a limited lymphadenectomy （DO and DI）. More extensive lymphadenectomy （DI＋/D2） seemed to have no impact on postoperative morbidity or 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.