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Background:  The aim of this study was to evaluate the safety and feasibility of simultaneous surgery for patients with primary esophageal and lung cancers., Methods:  Patients with primary esophageal and lung cancers who underwent simultaneous surgical procedures between January 2016 and January 2022 were retrospectively analyzed. The data of patients who underwent esophagectomy and lobectomy (group EL) were compared with those of patients who underwent esophagectomy and sublobar resection (group ES)., Results:  A total of 21 patients were included with an average age of 64.62 ± 5.24 years. Group EL contained 8 patients and group ES contained 13 patients. All procedures were completed uneventfully with a mean operative time of 251.19 ± 66.93 minutes. Pulmonary complications occurred in six (28.57%) patients. Other complications included anastomotic leakage in 1 patient, pleural effusion requiring drainage in 8 patients, atrial fibrillation in 2 patients, and incision infection in 1 patient. All patients were followed up for 30.23 ± 21.82 months. During the follow-up period, nine patients had a recurrence of cancer and died of tumor progression, and one patient died of a tracheothoracogastric fistula. Complications and mortality in group EL did not increase when compared to those in group ES., Conclusion:  It is safe and feasible to perform a single-stage surgical procedure for patients with primary esophageal and lung cancers. Simultaneous esophagectomy and lobectomy did not increase postoperative complications or mortality compared with esophagectomy and sublobar resection., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF., Methods: From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome., Results: In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously ( n  = 6, 40%) or metachronously ( n  = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy ( n  = 3), stenting ( n  = 6), or suturing ( n  = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition., Conclusion: Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating., Competing Interests: The authors have no conflict of interest., (Thieme. All rights reserved.)

Objectives: Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance., Methods: The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected., Results: A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging ( n  = 51 [42.5%] vs. n  = 13 [10.8%] respectively, p  < 0.05). Most of these were found in the lower lobes (61%). A higher rate of lesions was found among patients in whom the conduit was bulging to the right hemithorax compared with totally mediastinal or completely in the right hemithorax (54.5 vs. 35.2% and 34.6%, respectively, p  < 0.05). No correlation was found with conduit diameter or anastomotic site. These lesions were more prevalent among patients who complained of reflux or cough during meals (NS)., Conclusions: A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: Aorto-esophageal fistulae (AEFs) are a rare but serious and life-threatening disease of the mediastinum. Especially, AEF in the presence of infected stent grafts, for example, after thoracic endovascular aortic repair (TEVAR) is only curable by a multistage interdisciplinary surgical approach. This study presents the results of our four-stage approach consisting of bridging TEVAR, esophagectomy, complete stent removal followed by total bovine tube aortic replacement (TBTAR), and finally esophageal reconstruction., Methods: A case series of four patients from our department receiving a four-stage treatment of AEF is presented in this study. Retrospective database analysis focusing on overall survival, duration of intensive care unit and total hospital stay until discharge, complications, surgical time frame, and completion of chosen surgical treatment course was performed., Results: Overall, four patients surgically treated for AEF since May 2015 were included. A 30-day mortality was 0%, and overall survival at 1 year was 75%. All patients survived more than 5 months and could be discharged after TEVAR and esophagectomy. TBTAR could be performed in two of four patients (50%). Esophageal reconstruction was completed in all patients. Average follow-up was 20.3 ± 1.7 months or until death., Conclusion: The acute management of AEF using this approach seems satisfactory, especially for reducing acute short-term mortality. Complete restoration of the circulatory system and digestive tract remains challenging and is associated with high morbidity. We support the application of bridging TEVAR with a staggered approach to further surgical treatment individually tailored to the patient., Competing Interests: None., (Thieme. All rights reserved.)

Competing Interests: None declared.

Background: The main purpose of this study was to compare the postoperative complications caused by surgical reconstruction via either retrosternal (RS) or prevertebral (PV) routes in thoracoscopic and laparoscopic esophagectomy patients., Materials and Methods: We retrospectively screened the perioperative data in total 59 patients who underwent minimally invasive esophagectomy in time period from January 2016 to January 2018. All the patients were subgrouped into two cohorts according to the surgical routes being taken: the RS route group (28 patients) and the PV route group (31 patients). The perioperative data including operation and hospitalization time and surgical complications were comparatively analyzed., Results: The surgical procedure in all patients was successful and no case of death occurred during perioperative stage in both groups. Notably, patients in the RS group had significantly lower propensity of pneumonia than patients in the PV group ( p  < 0.05). However, comparative analysis revealed almost an identical time for both operative process and postoperative hospitalization. And there was no statistical significance in the rate of anastomotic leakage and stricture as well as other complications ( p  > 0.05)., Conclusion: RS and PV paths are both safe and effective routes that yielded similar postoperative complications. Reconstruction after thoracoscopic and laparoscopic esophagectomy via the RS route had lower propensity of pneumonia than PV route., Competing Interests: None., (Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany.)

Background:  Esophageal gastrointestinal stromal tumors (E-GISTs) represent less than 1% of all GISTs. The rarity of this lesion precludes the realization of randomized studies, and its treatment remains a matter of debate. We aimed to evaluate the feasibility of enucleation by video-assisted thoracic surgery (VATS) for low- to intermediate-risk E-GIST., Methods:  We performed a retrospective review of patients treated by enucleation through VATS between January 2004 and January 2014 and reviewed the literature., Results:  We included five patients (four men and one woman). Mean age was 53 years (range: 49-79). Three patients were diagnosed because of dysphagia and two others incidentally. The diagnosis was made by immunostaining demonstrating CD117 expression on tumor cells. The mitotic index of all E-GISTs was low (≤ 5 per 50 high-power field). Median postoperative follow-up was 5.5 years, and there was no recurrence., Conclusion:  Thoracoscopic enucleation of E-GIST seems to represent a valuable option as the postoperative morbidity/mortality is low and the oncological outcome is good for low-to-intermediate grade of malignity tumors.This is a retrospective study focused on minimally invasive treatment of E-GIST. We evaluated the feasibility of VATS enucleation of low-to-medium grade of malignity E-GIST., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The aim of this retrospective study was to access the impact of endoscopy intervention in anastomotic leak., Methods:  A retrospective review was conducted at our hospital from January 2008 to December 2016. In total, 263 patients who were diagnosed with an anastomotic leak after esophagectomy and underwent endoscopy examination were included in this study. First, all patients were divided into two groups based on a single criteria-whether they received endoscopy intervention or not-and comparisons were conducted between the two groups. Second, we categorized all patients into three groups based on the diameter of the anastomotic leak (group I: <5 mm; group II: 5-15 mm; group III: >15 mm). Detailed analyses were made for each group. Factors we considered included demographic factors, the length of postoperative hospital stay, the amount of medical expenditure, limited days of oral intake, and the incurrence of complications. Data relating to those factors were collected and then analyzed using standard statistic tools., Results:  In general, the difference between endoscopy intervention and conservative measure was significant. Moreover, the hospital stay ( p  < 0.001; p  = 0.018), medical expenditure ( p  < 0.001; p  = 0.003), limited days of oral intake ( p  < 0.001; p  = 0.019), and postoperative complications such as hemorrhage ( p  < 0.001; p  = 0.036), tracheoesophageal fistula ( p  = 0.002; p  = 0.017), and anastomosis stricture ( p  = 0.03; p  = 0.026) were significantly lower among patients who received endoscopy intervention in groups II and III. However, no significant difference was identified between endoscopy intervention and conservative measure in group I., Conclusions:  Endoscopy intervention is safe and effective in the diagnosis and treatment of postesophagectomy anastomotic leak. Especially for patients with a diameter of anastomotic leaks greater than 5 mm, the advantages of endoscopy intervention should not be neglected., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Total esophagectomy for esophageal cancer is associated with high morbidity. The avoidance of a thoracic access could especially reduce the occurrence of pulmonary complications. Therefore, the combination of a high transhiatal dissection of the esophagus and a neck access with mediastinal dissection of the esophagus appears to be a possibility to reduce the pulmonary risks. However, the access to the posterior mediastinum is very limited with the conventional minimal invasive instruments. These limitations can be overcome by the use of a surgical robot.In this article, we present a novel operation technique for a complete robot-assisted (da Vinci Xi) McKeown procedure avoiding a thoracic approach and abdominal incision by using a rendezvous technique with an abdominal and cervical docking of the robot system., Competing Interests: JHE is paid by Intuitive Surgery for proctoring surgical teams. TB received the da Vinci Xi robotic surgical system from Intuitive Surgical for the purpose of clinical research. The other authors have no conflicts of interest to declare., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  The incidence of esophageal carcinoma is increasing in the western world, and esophageal resection is the essential therapy. Several studies report advantages of minimally invasive esophagectomies (MIEs) versus conventional open procedures (OPs). The benefits of the use of fully MIE or robot-assisted MIE (RAMIE) compared with the hybrid approaches (laparoscopic gastric preparation and open transthoracic esophagectomy) remain unclear., Methods:  Between July 2015 and August 2017, the data of 75 patients with esophageal carcinoma were prospectively registered. Of the 75 patients, 25 treated with a hybrid MIE (hybrid), 25 with total MIE (MIE), and 25 with RAMIE. All patients were operated by the same specialized surgeon in our center with an identical anastomotic technique (circular stapler)., Results:  The overall 30- and 90-day mortality rates were 0 and 1.33% (1/75), respectively. Total hospital stay ( p  = 0.262), intensive care unit stay ( p  = 0.079), number of resected lymph nodes ( p  = 0.863), and R status ( p  = 0.132) did not differ statistically between the groups. However, pneumonia and wound infections occurred significantly and more frequently in the hybrid group compared with the minimally invasive groups (MIE and RAMIE) ( p  = 0.046 and p  = 0.003, respectively)., Conclusion:  Comparable results regarding morbidity and short-term outcome could be achieved in the MIE and RAMIE groups compared with the hybrid group. The data indicate that the learning curve is low in surgeons changing the technique form hybrid esophagectomy to fully MIE. Additionally, the total minimally invasive approaches seem to be associated with a low incidence of complications such as pneumonia and wound infections., Competing Interests: Peter Grimminger is a proctor for Intuitive Surgical., (Georg Thieme Verlag KG Stuttgart · New York.)

In esophagectomy for thoracic esophageal cancer, chylothorax may develop at a certain frequency. For chylothorax, conservative treatment is selected first, but if it is not improved, thoracic duct (TD) ligation is considered. In general, transthoracic approach is chosen to reach the TD. However, it is sometimes difficult to identify the TD due to adhesion in the thoracic cavity. Hence, we selected a laparoscopic transhiatal approach to the TD. We introduce the procedure of our laparoscopic transhiatal TD ligation technique., Competing Interests: The authors have no conflict of interest or commercial support., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Minimally invasive Ivor Lewis esophagectomy (MIILE) is increasingly being used in the treatment of middle or lower esophageal cancer. Hand-sewn purse-string stapled anastomosis is a classic approach in open esophagectomy. However, this procedure is technically difficult under thoracoscopy. The hardest part is delivering the anvil into the esophageal stump. Herein, we report an approach to performing this step under thoracoscopy., Methods:  A total of 257 consecutive patients who underwent MIILE between April 2013 and July 2017 were analyzed retrospectively. The operator hand sewed the purse string using silk thread under thoracoscopy, and the 25-mm circular stapler was passed through the anterior axillary line at the fourth intercostal space to finish the side-to-end gastroesophageal anastomosis. Patient demographics, intraoperative data, postoperative complications were evaluated., Results:  The mean operative time, thoracoscopy time, and anvil fixation time was 307.0 ± 34.3, 155.4 ± 21.5, and 7.1 ± 1.6 minute, respectively. The anastomotic leak and anastomotic stricture occurred in 6.6% (17 of 257) and 3.9% (10 of 257) of patients, respectively. There was no intraoperative death; one case was death of acute respiratory distress syndrome (ARDS) for conduit gastric leakage on the 21st postoperative day., Conclusion:  Using the hand-sewn purse-string stapled anastomotic technique for MIILE is feasible and relatively safe in patients with middle or lower esophageal cancer., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Postoperative atrial fibrillation (POAF) is associated with increased morality rate, prolonged hospitalization, and reduced long-term survival after surgery. Thus, prediction of POAF is important to assess surgical risk and provide prophylaxis., Methods: It was a prospective study of 207 consecutive patients who underwent a routine preoperative laboratory testing before thoracic surgery from October 2016 to May 2017. Comprehensive data were collected. Then stepwise multivariate logistic regression analysis was adopted to identify significant risk factors associated with POAF from various variables., Results: As results, three variables as follows: male gender, open thoracotomy, and B-type natriuretic peptide (BNP) exceeding 59 pg/mL were considered as independent risk factors associated with POAF ( p  < 0.05)., Conclusion: In patients undergoing noncardiac thoracic surgery, we found that an elevated preoperative BNP level (with the level of 59 pg/mL as a cutoff), male gender, and open-chest surgeries were significant risk factors for POAF. The identification of patients who are prone to develop POAF will provide prevention strategies to reduce this complication., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Minimally invasive esophagectomy (MIE) Ivor Lewis has been increasingly performed over the last two decades. To guide the implementation of this technically demanding procedure, a comprehensive assessment of MIE-Ivor Lewis learning curves should include both the general competence to accomplish the procedure and the ability to generate oncological benefits. These objectives are believed to be associated with different phases of the learning curve., Methods: A retrospective review of the first 109 patients who underwent MIE-Ivor Lewis by a single qualified surgeon was conducted. Relevant variables were collected and assessed by regression analysis to identify suitable indicators for patient stratification and learning curve assessment. Thereafter, the differential analysis was performed among groups to validate the learning curve model., Results: Two variables, intrathoracic gastroesophageal anastomosis time and bilateral recurrent laryngeal nerve (RLN) lymphadenectomy number, which plateaued, respectively, after the 26th and 88th cases, were selected as meaningful indicators to identify different competence levels. Therefore, 109 patients were chronologically subcategorized into three groups (the first 26 MIEs as the early group, the next 62 cases as the middle group, and 21 most recent cases as the late group). Perioperative data were compared between groups with positive results to indicate a three-phase model for a learning curve for MIE-Ivor Lewis., Conclusions: An MIE-Ivor Lewis learning curve should include three discrete phases that indicate, successively, unskilled operation (general competence to accomplish, less proficiency), surgical proficiency, and oncological efficacy. Intrathoracic anastomosis time and bilateral RLN lymphadenectomy were identified as suitable indicators delineate the different stages of an MIE-Ivor Lewis learning curve., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Anastomotic leaks significantly affect hospital stay after esophageal surgery. Here, we investigated the efficacy of early endoscopy for predicting anastomotic healing and leaks after esophageal reconstruction., Methods: A total of 65 consecutive esophageal cancer patients treated by cervical esophagogastrostomy underwent routine endoscopy between postoperative days 5 and 7. The anastomosis was scored for the degree of ischemia, stenosis, and torsion of the anastomotic axis. Independent associations between ischemia, stenosis, and torsion of the proximal esophagus and the risk of the anastomotic leak were examined using Spearman's rank correlation method., Results: Assessment of the degree of mucosal ischemia in 65 patients shows well healing in 35, patch ischemia in 20, diffuse ischemia in 10, no necrosis in any patient. Stenosis was classified as 0 to 10% in 40 patients, 11 to 20% in 12, 21 to 80% in 11, and 81 to 100% in 2. The degree of torsion of the anastomotic axis was classified as 0 to 10 degrees in 52 patients, 11 to 90 degrees in 8, and 91 to 180 degrees in 5. With rising endoscopy scores, there was an increase in risk for leaks (score > 4.5, sensitivity 100%, and specificity 83.8%)., Conclusions: Early postoperative endoscopy facilitates the management of esophagogastrostomy anastomosis to predict leaks., Competing Interests: Tzu-Hsin Lin and Pei-Ming Huang have no conflicts of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Totally minimally invasive esophagectomy (MIE) is nowadays en vogue.1 2 3 4 5 There are several reports showing that already partial minimally invasive esophagectomies (hybrid esophagectomies) with a laparoscopic approach and open transthoracic resection are beneficial for patients due to the reduced operative trauma. Also for total MIE several groups have reported benefits for patients in terms of morbidity and quality of life.1 5 However, different approaches and experiences of different esophageal surgery groups are hardly comparable and thus do not allow a simple answer in favor of a specific total MIE technique. To enlighten the field of total MIE, we present the technique as we perform this procedure nearly weekly in our department. The described MIE technique is safe and feasible. Changing to this demonstrating technique, we did not have any mortality so far, even in the first 30 cases. Especially for surgeons who plan to switch from the open surgical technique toward hybrid, MIE or robotic-assisted MIE., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: We aimed to assess the feasibility, surgical outcomes, and conduit-related complications of colon interposition in patients with esophageal cancer., Methods: Patients with esophageal cancer who underwent colon interposition for esophageal reconstruction between June 2000 and June 2013 were retrospectively reviewed., Results: A total of 67 consecutive patients (mean age, 62.2 ± 7.9 years) were enrolled. During this time period, 944 patients underwent esophageal reconstruction using gastric conduit. Twelve patients (17.9%) also received neoadjuvant chemoradiotherapy (nCRT). The median follow-up duration was 44 months (range, 1-168 months); median survival duration was 63 months (range, 1-168 months); and 3- and 5-year overall survival rates were 61.6 and 49.4%, respectively. A total of 43 patients (64.2%) experienced at least 1 postoperative morbidity. According to the Clavien-Dindo grading system, 36 patients (54%) experienced postoperative morbidity of higher than Grade III. Pulmonary complications were most commonly observed complications among the patients (18 patients, 26.9%). Anastomosis site leakage developed in 11 patients (16.4%), and 3 of these patients (6.0%) eventually experienced graft failure. On multivariate analysis, nCRT was determined as a significant risk factor for conduit-related complications (leakage, graft failure, fistula, and stricture)., Conclusion: Colon interposition is associated with relatively high complication rates, whereas nCRT is associated with conduit morbidity., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: There is no consensus on the effectiveness of prophylactic thoracic duct ligation (PLG) in esophagectomy for reducing the incidence of postoperative chylothorax. We performed a systemic review and meta-analysis to study its efficacy., Methods: A systemic review of the publications was performed on three databases to identify all the relevant literature on comparative outcomes of PLG and nonprophylactic thoracic duct ligation (NPLG). The primary end point was the incidence of postoperative chylothorax., Results: Seven studies with comparative data on PLG ( n  = 2,178) versus NPLG ( n  = 3,048) were identify from the current publications. Comparison showed no significant difference between PLG and NPLG on the incidence of postoperative chylothorax (relative risk = 0.431; 95% confidence interval, 0.186 to 1.002; p  = 0.050)., Conclusions: Although some studies showed that PLG during the esophagectomy was effective to lower the incidence of postoperative chylothorax, no evidence was observed in the present meta-analysis. Further research is warranted to validate the findings., Competing Interests: The authors have no conflict of interest to declare., (Georg Thieme Verlag KG Stuttgart · New York.)

Robotic-assisted surgery is rapidly increasing, especially in general surgery. It has been shown for years that the minimal invasive esophagectomy (MIE) is possible using a robotic system, for example, da Vinci Xi, Intuitive Surgical. In the past, most robotic esophageal resections have been performed thoracoscopically, and the anastomosis was mostly sutured at the neck. Due to the increase of usable instruments and technical progress, it is possible to perform the total abdominothoracic esophagectomy with an intrathoracic sutured anastomosis robotically. In this article, we would like to present the standardized operation technique and tricks for the robotic-assisted (da Vinci Xi) Ivor Lewis MIE (RAMIE), especially the robotic technique in combination with a standardized intrathoracic circular end-to-side stapled esophagogastric anastomosis., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Robotic surgery is gaining importance in complex thoracoscopic surgery, such as robotic-assisted minimally invasive esophagectomy (RAMIE). The RAMIE procedure was designed using the first generation of the robotic system. The latest da Vinci Xi system has substantially increased the dexterity, especially designed for multiquadrant surgery. The original three-arm RAMIE approach was modified including the robotic four-arm use for the thoracoscopic and laparoscopic part of the operation. This extended approach (four-arm RAMIE approach) provides more flexibility and raises the independence of the surgeon., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Chylothorax is a rare complication after thoracic trauma or surgery, especially oesophagectomy, which, if left untreated, can be potentially life-threatening., Methods: This article provides an overview of the existing literature on the prevention and surgical therapy of chylothorax., Results: The risk of chyle leakage after oesophagectomy increases with the difficulty of mediastinal dissection and is reported to be around 3% for oesophagectomy. With this risk, there is the possibility of a prophylactic intraoperative ligature of the thoracic duct, either as a selective or mass ligation. Meta-analyses confirm the effectiveness of this measure, with a reduction in the risk to less than 1%. In the case of postoperative chylothorax, a conservative therapeutic trial may be undertaken with drainage of up to 1000 ml per day for up to one week. If there is any indication of persistent leakage, rapid surgical reintervention appears appropriate. This can be either transthoracic or transhiatal as a selective or mass ligation and has a probability of success of over 90%., Conclusion: The prophylactic primary or therapeutic secondary ligature of the thoracic duct is an effective surgical preventive measure and therapy of postoperative chyle leakage., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Esophagectomy for cancer is a highly complex and demanding two-cavity procedure associated with a considerable morbidity and mortality. There are several controversies with regard to the optimal risk and complication management. Strategies include patient selection, optimization of malnutrition, hospital and surgeon volume, intraoperative anesthesiological and surgical measures, and postoperative management of complications. In this article, we review the literature on these aspects that have an impact on outcomes after esophagectomy., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  In patients with synchronous esophageal and gastric cancers, selecting an optimal conduit for esophageal reconstruction is a critical decision. The aim of this study was to evaluate the surgical outcomes after simultaneous resection of esophageal and gastric cancers according to the type of esophageal conduit used. Materials and Methods  Clinicopathologic features and surgical outcomes were analyzed in 66 patients who underwent esophageal reconstruction with colon ( n  = 41, group C), jejunum ( n  = 11, group J), and stomach ( n  = 14, group S). Results  Gastric cancer was adenocarcinoma and esophageal cancer was squamous cell carcinoma in every case. Inhospital mortality rate was 4.6% ( n  = 3). The complication rates were 6.1% for graft failure and 9.1% for anastomotic leakage. During the follow-up period (mean, 44.0 ± 49.6 months), 5-year overall and disease-free survivals were 50.6 and 48.1%, respectively. Especially, patient with stage I cancer for both esophageal and gastric lesion showed excellent survival outcome with 5-year overall survival rate of 82.0%. There were no significant differences in early mortality, incidence of graft complications or overall survival between the groups. The independent predictors of overall survival were the highest tumor stage ( p  = 0.008) and age ( p  = 0.009). Conclusion  Simultaneous resection of gastric and esophageal cancers can be performed with reasonable early and late outcomes. The type of esophageal conduit used was not a determinant factor for early and late outcomes., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Thoracoscopic-laparoscopic procedures have been used more in the operations of esophagus cancer; in most times we call it minimally invasive esophagectomy, which is becoming mature. However, the efficacy of minimally invasive esophagectomy is still unclear, especially about the dissection of lymph nodes and survival. Methods  A retrospective review was performed. The development process of minimally invasive esophagectomy for esophageal cancer was divided into three stages: the first stage 20, the second stage 37, the third stage 50. Result  Total 107 patients underwent minimally invasive esophagectomy between July 2010 and May 2015. The number of lymph node resected during the three stages increased significantly, with a mean of 12.65, 15.91, and 20.16 nodes, respectively ( p  = 0.0075). The number of lymph nodes dissection greater than or equal to 12 or 18 increased significantly ( p  = 0.000). The patients from the first and the second stages had the similar 2-year survival rate ( p  = 0.8618). There is no significant difference in the 2-year disease-free survival rate ( p  = 0.606). Conclusion  Surgeons accumulate experience on lymphadenectomy during minimally invasive esophagectomy as time goes by, and experience on 50 to 60 cases is essential and necessary to accomplish an apparent progress., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Esophageal cancer is a malignant tumor with one of the worst prognosis. Positron emission tomography (PET) reveals the degree of metabolic activity of tumor cells. We hypothesized that a high maximum standardized uptake value (SUVmax) on PET would predict a poor clinical outcome., Methods: From November 2004 to August 2011, we reviewed 88 patients with esophageal squamous cell carcinoma who underwent preoperative PET followed by surgery. SUVmax values of primary sites were measured. The patients were divided into two groups with median SUVmax as a cutoff value and outcomes were compared., Results: The median SUVmax was 6.35. Cervical and upper thoracic cancer, large tumor size, stage ≥ T2, and lymph node metastasis were significantly associated with the high SUVmax group. Cervical and upper thoracic cancer (p = 0.038), SUVmax (p = 0.038), number of lymph nodes dissected (p = 0.009), stage ≥ T2 (p = 0.003), lymph node metastasis (p < 0.001), and incomplete resection (p = 0.031) were significant predictors for the disease-free survival. A high SUVmax ( ≥ 6.35, p = 0.023) and stage ≥ T2 (p = 0.025) were significantly associated with overall survival by multivariate analysis., Conclusion: High preoperative SUVmax on PET predicts advanced T stage and worse prognosis. SUVmax on PET may provide useful information combined with current stage for determining optimal treatment in esophageal cancer., (Georg Thieme Verlag KG Stuttgart · New York.)

Backgrounds: What is the optimal way for the middle esophageal cancer? It is still controversial. In this study, the clinical outcome of middle thoracic esophageal cancer with either intrathoracic or cervical anastomosis was analyzed in our department., Patients and Methods: A total of 205 patients who suffered from middle thoracic esophageal cancer were divided into two groups. In group A, 91 patients received intrathoracic anastomosis above aortic arch after esophageal resection via single left thoracotomy, and in group B, 114 patients received cervical anastomosis after esophageal resection via right thoracotomy and median laparotomy. Data of these patients were collected, and morbidity and mortality were analyzed retrospectively. Survival rate was estimated using the Kaplan-Meier method and comparisons between groups were performed with log-rank test. Univariate and multivariate analyses were performed using Cox model to look for independent predictors of survival., Results: Postoperative complications occurred more frequently in group B, such as hemorrhage (p = 0.011), wound infection (p = 0.032), and temporary paresis of the recurrent laryngeal nerve (p = 0.001). Morbidity of anastomotic leak was higher in group B (8.8 vs. 2.2%; p = 0.048), but the associated mortality was not increased. The extent of radical esophagectomy and lymphadenectomy was much greater in group B; therefore, longer esophagus was resected that reduced the cancer residual rate, and more positive lymph nodes were detected that enhanced the accuracy of clinical staging. Fortunately, more patients received adjuvant therapy after operation in group B, and the 5-year survival rate was improved., Conclusion: Anastomotic leak rate was higher in cervical anastomosis but with lower mortality. The 5-year survival rate was improved in cervical anastomosis group. The present data support the assumption that cervical anastomosis is a safer and more beneficial procedure for patients with middle thoracic esophageal cancer., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this study was to evaluate the role of the maximum standardized uptake value (mSUV) of the main mass as a risk factor for recurrence in patients with completely resected esophageal squamous cell carcinoma (ESCC)., Patients and Methods: Clinicopathologic factors including primary tumor location, tumor size, depth of tumor invasion, number of positive lymph nodes, angiolymphatic invasion, and mSUV were analyzed as risk factors for recurrence. The prognostic influence of variables on disease-free survival was analyzed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis., Results: A total of 102 patients underwent complete resection of ESCC and positron emission tomography/computed tomography was performed. The median follow-up period was 35.0 months (range, 2-94). The average mSUV of the main mass was 5.5 ± 4.2. The tumor had recurred in 38 patients (37.3%). Univariate analysis identified that tumor size (> 3.5 cm), depth of tumor invasion (≥ T2), pathologic stage, and mSUV (> 5.1) were statistically significant prognostic factors for recurrence of ESCC. However, in multivariate analysis, only mSUV (> 5.1, HR = 4.222, p = 0.025) was the independent risk factor of recurrence., Conclusions: The mSUV of the main mass was an independent predictor for recurrence with a cutoff value of 5.1., (Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: Thoracoscopic esophagectomy in the prone position (ThE-PP) is usually performed with four ports, which makes the operation almost solo surgery. We now perform ThE-PP with five ports, with the advantage of having the assistant able to provide additional help. The aim of this study was to elucidate the benefits of ThE with five ports over ThE with four ports., Methodology: We retrospectively reviewed the clinical charts of 47 patients with esophageal cancer who underwent ThE-PP. A total of 14 patients underwent ThE-PP with four ports and 33 with five ports. We compared the number of dissected lymph nodes (LNs)--total; upper left, middle, and lower mediastinum--between the four-port and five-port groups., Results: The number of LNs dissected, including the total, the upper left and middle mediastinum, were not significantly different between the two operations. The number of LNs dissected from the lower mediastinum, however, was significantly higher in the five-port group (median number and interquartile range: 5 and 2-7, respectively) than in the four-port group (0.5 and 0-3, respectively) (P < 0.01)., Conclusions: ThE-PP performed with five ports has an advantage over the same operation done with four ports in terms of lymphadenectomy in the lower mediastinum.

Background/aims: This study was designed to evaluate the safety and efficacy of endoscopic excavation for esophageal subepithelial tumors originating from the muscularis propria., Methodology: Forty-five patients with esophageal subepithelial tumors originating from the muscularis propria were treated with endoscopic excavation between January 2010 and June 2012. The key steps were: (1) making several dots around the tumor; (2) incising the mucosa along with the marker dots, and then seperating the tumor from the muscularis propria by using a hook knife or an insulated-tip knife; (3) closing the artificial ulcer with clips after the tumor was removed., Results: The mean tumor diameter was 1.1 ± 0.6 cm. Endoscopic excavation was successfully performed in 43 out of 45 cases (95.6%), the other 2 cases were ligated with nylon rope. During the procedure perforation occurred in 4 (8.9%) patients, who recovered after conservative treatment. No massive bleeding or delayed bleeding occurred. Histologic diagnosis was obtained from 43 (95.6%) patients. Pathological diagnoses of these tumors were leiomyomas (38/43) and gastrointestinal stromal tumors (5/43)., Conclusions: Endoscopic excavation is a safe and effective method for the treatment of small esophageal subepithelial tumors originating from the muscularis propria.

Background/aims: The objective of this study was to evaluate the efficacy and safety of landiolol hydrochloride, a newly developed ultra-short-acting β1-selective blocker, for postoperative tachyarrhythmia after esophagectomy., Methodology: In total 231 patients underwent transthoracic esophagectomy at the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine from 2007 to 2012. Twenty-four patients who were treated with either landiolol hydrochloride (n = 11) or conventional agents (combination of calcium channel blocker and digitalis preparation; control group, n = 13) for postoperative tachyarrhythmia after transthoracic esophagectomy were retrospectively analyzed. Tachyarrhythmia was defined as a heart rate of >120 bpm or atrial fibrillation. Hemodynamic changes, conversion rates, and adverse events were evaluated., Results: The reduction in the heart rate at 1 h after medication was seen significantly more frequent in the landiolol group than in the control group. The time to conversion to sinus rhythm was also significantly shorter in the landiolol group. There were no significant differences between the two groups in blood pressure either before or after the medication. One patient in the landiolol group showed hypotension and bradycardia, without serious consequences., Conclusions: Landiolol hydrochloride can be effectively and safely used in patients who develop tachyarrhythmia after esophagectomy.

Esophagectomy (EE) and pancreatoduodenectomy (PDE) are considered the most invasive and technically demanding surgical procedures performed on the digestive organs. These surgical interventions significantly change the normal anatomic relationships in the upper abdomen. Any additional digestive surgeries, especially resectional procedures, performed after a prior EE or PDE can be extremely difficult. The cases of simultaneous or metachronous EE and PDE in the same patient are very interesting from both a scientific and a practical viewpoint. We collected and analyzed the existing literature data on EE and PDE in the same patient. There were 60 cases: 3 cases of EE after PDE, 22 cases of PDE after EE, and 35 cases of simultaneous EE and PDE. The technical and tactical features of the surgery in a different sequence of stages or in a simultaneous procedure are discussed in a review.

Gastrointestinal fistula is the most serious complication of esophageal and gastric cardiac cancer surgery. According to occurrence of organ, gastrointestinal fistula can be divided into anastomotic fistula, gastric fistula; According to occurrence site, fistula can be divided into cervical fistula, thoracic fistula; According to time of occurrence, can be divided into early, middle and late fistula. There are special types of fistula including ‘thoracic cavity’-stomach-bronchial fistula, ‘thoracic cavity’-stomach-aortic fistula. Early diagnosis needs familiarity with various types of clinical gastrointestinal fistulas. However, Prevention of gastrointestinal fistula is better than cure, including perioperative nutritional support, respiratory tract management, and acid suppression, positive treatment of complications, antibiotic prophylaxis, and gastrointestinal decompression and eating timing. Prevention can effectively reduce the incidence of postoperative gastrointestinal fistula. Collectively, early diagnosis and treatment, nutritional supports are key to reducing mortality of gastrointestinal fistula.

Background/aims: Here we investigated postoperative prognostic factors and surveillance in patients with esophageal cancer. METHODOLOGY Prognostic factors were evaluated at several different postoperative stages in 257 patients with curative (R0) esophagectomy. Cause of death and pattern of tumor recurrence were also analyzed., Results: There was a significant difference in the distribution of cause of death according to the time after surgery (p<0.001). The pattern of recurrence also differed according to the time after surgery, although this was not statistically significant. A Cox proportional regression hazard model for disease-specific survival revealed that Tumor-Node-Metastasis (TNM) stage was an independent prognostic factor only from the time of initial surgery until the third postoperative year, and no postoperative prognostic factors were detected after the fourth and fifth years. There were significant differences in disease-specific survival among pathological TNM stages between the time of initial surgery and postoperative year five, but not between stages I and II at postoperative years two, three, or four. There were no significant differences between the stages at postoperative year five. Relapse-free survival differed between stages II and III at postoperative year five, although the other results were similar to those for disease-specific survival., Conclusions: Prognostic factors for esophageal cancer alter during the postoperative period. Although the pathological stage at the time of initial surgery has less prognostic power after 3 years, it remains important to monitor treatments for esophageal cancer continuously, as well as concomitant diseases and other malignancies.

Background/aims: MuItimodality treatment improves esophageal squamous cell carcinoma (ESCC) prognosis, however the most optimal treatment still remains controversial., Methodology: In 213 ESCC patients who had operation at Kitasato University Hospital between 1996 and 2007, prognosis was evaluated in terms of cStage and adjuvant therapy., Results: Survival outcome of with the 62 cStage I ESCC were excellent (2 recurrences) with infrequent postoperative treatment (Adj). Of 129 ESCC patients with cStage II/III, 45 patients including suspicious cT4 (cT3.5) were given neoadjuvant therapy (Neo), and pStage 0/I patients showed excellent prognosis. Of 84 cStage II/III patients not given Neo, 67 (79.8%) underwent R0 esophagectomy, among whom 20 cases had pN0 (pStage II/IIa) with 3 recurrences (15%) despite infrequent Adj. On the other hand, among the 45 cStage II/III patients with Neo, 8 pStage IIa patients exhibited poor prognosis with 5 recurrences (62.5%) as well as pStage III/IV. In pStage IIb ESCC, cStage IIa showed poorer prognosis than cStage I/IIb (P = 0.0072). Among the 21 cStage IV ESCC patients, 5 long-term survivors were experienced by multimodality treatments., Conclusions: Both cStage and Neo greatly affect ESCC prognosis irrespective of identical pStage, which must be allowed for in order to determine therapeutic strategy against ESCC.

Background/aims: The aim of the present study was to clarify the results and feasibility of surgical approaches for cancer, which is mainly occupied by squamous cell carcinoma (SCC), of the lower esophagus., Methodology: Forty-four patients (34 men, 10 women) with cancer located at the lower esophagus were enrolled in this study. SCC was diagnosed in 36 cases and adenocarcinoma (ADC) in 8 cases. Thirteen patients underwent transhiatal esophagectomy, 18 underwent lower thoracic esophagectomy by left thoracotomy, and 13 underwent esophagectomy with a right thoracic approach by open thoracotomy or thoracoscopy., Results: Ten cases (ADC, n = 2; SCC, n = 8) showed involvement of mediastinal lymph nodes, although lymph node dissection varied with each surgical approach. Five-year survival rates were 75% for ADC and 31.9% for SCC, and ADC tended to be associated with a more favorable prognosis than SCC (p = 0.058). Transhiatal esophagectomy was performed more often in older patients (p < 0.05), but no other clinicopathological parameters appeared to affect the selection of surgical approach. No significant prognostic differences existed between surgical approaches (p = 0.35), even though the examination was limited to SCC (p = 0.98)., Conclusions: No significant prognostic differences were identified between transhiatal and left and right transthoracic approaches for lower esophageal cancer.

Background/aims: Reconstruction using a free jejunal graft (FJG) after resection of the cervical esophagus has become common, but postoperative morbidity remains. We report herein our procedure and the results of reconstruction for neck cancer using FJGs., Methodology: Twenty-four patients underwent FJG reconstruction after laryngo-pharyngo-esophagectomy. We perform a mini-laparotomy with a 5-cm para- or trans-rectus muscle incision. The FJG is then harvested from the jejunum supplied by the second or third mesenteric artery, and a jejunostomy is created. Pharyngo-jejunal anastomosis is performed using an Albert-Lembert suture and jejunal-esophageal anastomosis by a circular stapling technique. The facial artery or suprathyroid artery is used as the feeding artery, and the common facial vein or external jugular vein as the drainage vein. Vascular anastomosis is performed microsurgically., Results: In terms of postoperative morbidity, minor anastomosis leakage of the pharyngo-jejunal anastomosis was observed in one patient, stricture of the jejunal-esophageal anastomosis in four, and wound infection in one. No cases of passage disorder due to graft bending were seen, and no patients died., Conclusions: The procedure using FJG harvested via mini-laparotomy is minimally invasive and is a feasible procedure for reconstruction after laryngo-pharyngo-esophagectomy, resulting in low morbidity.

Background/aims: A retrospective analysis of therapeutic modalities used in postoperative recurrent esophageal cancer., Methodology: Among 43 esophageal cancer patients who underwent esophagectomy between 2003 and 2010, recurrence was found in 15. Best supportive care was given to two patients and another patient was referred to another hospital. The remaining 12 patients were treated by the following modalities: Surgical resection: 2 cases; chemoradiotherapy: 7 cases; chemotherapy: 2 cases; and radiotherapy: 1 case. The median survival time, 1-year survival rates, and response rates were examined. Data from 13 esophageal cancer patients who underwent chemoradiotheray as an initial therapy in the same period were collected and compared with recurrent cases treated with chemoradiotherapy., Results: For all 12 patients, the median overall survival time was 19.5 months, and the 1-year survival rate was 83%. Among 7 chemoradiotherapy patients, the response rate was 57%. The median survival time was 23 months, and the 1-year survival rate was 86%. The response rate of 13 patients receiving chemoradiotherapy as an initial therapy was 69%. The median overall survival time was 12 months and the 1-year survival rate was 54%., Conclusions: Re-operation and chemoradiotherapy for recurrent esophageal cancer might be as effective as the same treatment used initially.

Background: The aim of our study was to develop a prognostic index score for patients undergoing surgical resection for esophageal cancer that accurately determines survival with specific clinicopathological characteristics., Methods: Clinical, histological, and demographical variables of 475 patients were entered in an univariate and multivariate regression model, followed by individual calculation of the Prognostic Indicator Score and model validation via simulation., Results: Significant variables included in the scoring system were number of positive lymph nodes, pT, pL, R, obesity, and American Society of Anesthesiologist classification. Survival probability and its associated hazard function was significantly different between the scores, with an increase of hazard ratio ranging from 2.56 (score 2) to 20 (score 6 or higher). Comparing histological cancer entities revealed statistical significance only between stage IIA versus IIB in squamous cell and stage IIIA versus IIIB in adenocarcinoma., Conclusions: According to our methodology, an individualized follow-up by each possible score might allow interdisciplinary selection of patients for treatments based on expected survival. This may represent a breakthrough in patient selection for currently available treatments and clinical studies., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: To investigate the overexpression of Metastasis-associated gene 1(MTA1) protein and its relationship to the prognosis in esophageal squamous cell cancer after esophagectomy., Methods: 174 patients with middle third squamous cell carcinoma of the esophagus underwent complete resection in Provincial Hospital Affiliated to Shandong University between January 2002 and January 2005. The overexpression of MTA1 protein was detected by immunohistochemistry. Kaplan-Meier method was performed to calculate the survival rate, Cox regression multivariate analysis was performed to determine independent prognostic factors., Results: MTA1 protein overexpression rate in T1, T2, and T3 patients was separately 25.0, 31.9, and 53%, the difference of MTA1 protein overexpression between them was statistically significant (p = 0.017). The overexpression of MTA1 protein in patients with lymph node metastasis was significantly higher than those without metastasis (p = 0.042). MTA1 protein overexpression correlated with significantly worsened 5-year survival for all patients as well as those with T2 and T3 tumors, N0 nodal status or N1 nodal status. However, no significant correlations with T1 patients (p = 0.061). The result of Cox analysis demonstrated that N stage and MTA1 protein overexpression were independent prognostic factors., Conclusion: MTA1 protein overexpression was detected in esophageal squamous cell carcinoma and was found to be significantly associated with the T stage. The patients with MTA1 protein overexpression had a significantly lower 5-year survival rate than without MTA1 protein overexpression. Lymph node metastasis and MTA1 protein overexpression were independent prognostic factors., (Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy., Methodology: Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic., Results: Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms., Conclusions: While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Background/aims: To investigate the expression of vascular endothelial growth factor-C (VEGF-C) and its relationship to lymph node metastasis in esophageal squamous cell cancer after esophagectomy., Methodology: The expression of VEGF-C protein was detected by immunohistochemistry. Kaplan-Meier method was performed to calculate the survival rate. Cox regression multivariate analysis was performed to determine independent prognostic factors., Results: The difference of VEGF-C protein expression in Tl, T2 and T3 patients was statistically significant (p=0.031). The expression of VEGF-C protein in patients with lymph node metastasis was significantly higher than those without metastasis (p=0.004). VEGF-C protein expression correlated with significantly worsened 5-year survival for all patients as well as those with T3 tumors and N1 nodal status. The result of Cox analysis demonstrated that N stage and VEGF-C protein expression were independent prognostic factors; the multivariate analyses indicated that the N classification is the independent pathological risk factor of VEGF-C expression., Conclusion: VEGF-C expression was found to be significantly associated with T stage and N stage. The patients with VEGF-C protein expression had a significantly lower 5-year survival rate than without VEGF-C protein expression. Lymph node metastasis and VEGF-C protein expression were independent prognostic factors.

Thoracoscopic esophagectomy performed with the patient in the left lateral position has been occasionally reported since the 1990s, but it has not been established as a standard procedure. This may be because the success of this procedure largely depends on the technical competence of an assistant to secure an adequate field of view during the procedure. Thoracoscopic esophagectomy with the patient in the prone position has recently been introduced and has been consistently shown to be useful. Compared with left lateral thoracoscopic esophagectomy, prone thoracoscopic esophagectomy requires less assistance in exposing the operative field and it is relatively easy to obtain a satisfactory field of view. We performed prone thoracoscopic esophagectomy on 20 patients and were successful in achieving a wide field of view. The postoperative course was remarkably favorable in all patients and the procedure is considered promising for standard thoracoscopic esophagectomy. There are few detailed reports of this procedure; herein, we describe the procedure of prone thoracoscopic esophagectomy employed at our hospital.

Background/aims: Increased incidences of gallbladder disorders after esophagectomy and gastrectomy have been reported. Moreover, several researchers have reported increased incidences of gallbladder diseases in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis or cholestasis and determined its relationship with total parenteral nutrition; further, we compared the incidence after esophagectomy and after total gastrectomy., Methodology: We retrospectively studied 109 patients who underwent total gastrectomy or esophagectomy. These patients were divided into 2 groups, those who underwent total gastrectomy (TG group) and those who underwent esophagectomy (E group)., Results: The 2 groups did not significantly differ with respect to the mean duration of perioperative administration of total parenteral nutrition and the incidence rate of cholecystitis or cholestasis after esophagectomy., Conclusions: Postoperative hyperbilirubinemia after esophagectomy may not contribute to the development of gallbladder complications. We suggest that parenteral modalities such as tube feeding be initiated immediately after surgery for preventing gallbladder complications after esophagectomy. Further, a short duration of administration of total parenteral nutrition and immediate postoperative initiation of oral feeding may prevent gallbladder complications after esophagectomy and total gastrectomy.

Background/aims: The aim of this study is to compare and evaluate the therapeutic efficacy of Ivor-Lewis esophagectomy and one incision esophagectomy through left thoracic and above aortic arch anastomosis approach (left transthoracic esophagectomy) in order to choose a proper surgical procedure to treat middle esophageal carcinoma., Methodology: Patients who underwent Ivor-Lewis esophagectomy (n=132) and who underwent left transthoracic esophagectomy (n=52) between January 2003 and June 2005 were included. The survival rate was calculated by Kaplan-Meier method and the prognostic risk factors were assessed by Cox regression analysis., Results: Postoperative complications occurred in 43 patients (23.4%), with 31 patients (23.5%) and 12 patients (23.1%) in the Ivor-Lewis group and in the left transthoracic esophagectomy group, respectively. The overall 5-year survival rate was 36.4%, with 37.1% and 34.6% in the Ivor-Lewis group and in the left transthoracic esophagectomy group, respectively (p>0.05). In Cox regression analysis, T classification (HR=1.43, p=0.025) and N classification (HR=1.76, p=0.004) were the independent prognostic risk factors., Conclusions: Ivor-Lewis esophagectomy and left transthoracic esophagectomy are both feasible options to treat middle thoracic esophageal squamous cell carcinoma. Patients' individual condition is suggested to be taken into account when choosing the operative approach.

Background/aims: A high incidence of hyperbilirubinemia and an increased incidence of gallbladder disorders after esophagectomy have been reported. Moreover, several studies have documented an increased incidence of gallbladder disease in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis and cholestasis and hyperbilirubinemia associated with total parenteral nutrition after esophagectomy., Methodology: We retrospectively studied 42 patients who underwent esophagectomy. These patients were divided into 2 groups: the hyperbilirubinemia group and the non-hyperbilirubinemia group. The incidence of cholecystitis or cholestasis after the surgery was compared between the 2 groups., Results: The mean total serum bilirubin level of the hyperbilirubinemia group (2.40±0.35mg/dL) was significantly higher than that of the non-hyperbilirubinemia group (1.20±0.34mg/dL; p<0.0001). No significant differences were observed between the 2 groups with respect to the mean duration for which total parenteral nutrition was required around the time of the operation (i.e. pre- and postoperatively) and the incidence rate of cholecystitis or cholestasis after esophagectomy., Conclusions: Hyperbilirubinemia after esophagectomy was frequently observed; however, it may not contribute to gallbladder problems. We suggest that parenteral modalities such as tube feeding should be initiated soon after surgery to prevent gallbladder problems after esophagectomy.

Background/aims: To study the effects of a gastric tube anastomosis in the intraperitoneal operation for types II and III adenocarcinoma of the esophagogastric junction (AEG)., Methodology: Thirty-one patients with types II and III AEG were selected for proximal gastrectomy. After the proximal gastrectomy by the abdominal approach, the gastric remnant was cut into a tubular shape. The esophagus was then anastomosed to the gastric tube., Results: The surgical technique was performed on all 31 patients with types II or III AEG. The operation time was 279.52±34.99min, average surgery blood loss was 209.68±185.82mL, the number of hospital postoperative days was 10.48±2.01. All cases were followed-up for 2-12 months. One (3.2%) patient had postoperative anastomotic bleeding and another case had intractable hiccups. Only 3 (9.7%) patients felt heartburn after the operation. One (3.2%) patient was found to be suffering from reflux esophagitis through endoscopic examination. In addition, 1 (3.4%) patient had tumor recurrence., Conclusions: Using gastric tubes is a safe surgical technique and is followed by only a small number of complications at the early postoperative stage.

Background/aims: Neoadjuvant chemoradiotherapy (CRT) is widely applied in locally advanced esophageal tumors to improve resectability and local tumor control. In this study, we retrospectively analyzed the perioperative course of patients who underwent esophagectomy or esophagectomy following CRT., Methodology: Forty one patients were admitted with non-advanced disease (T1-2, N0), and primary resection was performed. Additional 21 patients received neoadjuvant CRT because of locally advanced, T2-4, N0-1 disease. To investigate predictive factors for responsiveness to CRT, we determined the p53, p21 and Ki67 oncogene expressions in the biopsy samples from the CRT patients., Results: Following primary esophagectomy and esophagogastrostomy, the postoperative course was in most cases uneventful. Anastomotic leaks developed in 3 of the 41 cases (7.3%), and postoperative death in 1 case (2.4%). In response to CRT, significant down-staging was observed in 11 of the 21 patients (58%); in these cases esophagectomy was performed. However, in this group the rates of anastomotic leak (2 patients) and postoperative death (2 patients) were higher than in the first group (18% each)., Conclusions: Preoperative CRT is a good option for patients with locally advanced tumors, when primary R0 resection is hopeless. However, the rate and risk of postoperative complications are higher than after primary resection of non-advanced tumors.

Background: Prevention, early recognition and an adequate management of perioperative complications in resectional oesophageal surgery are the keys to an increased safety of these complex procedures., Recognition, Diagnostics, Management and Treatment: Preoperative registration and - if required - pretreatment of specific risk factors can considerably decrease the complication rate. The precise implementation of significant preoperative score systems in patients with high operative risk can lead to a negative risk-benefit consideration concerning the indication for an operation. The patients will then be assigned to an alternative treatment process. Anastomotic leakage is the most frequent technical-surgical complication. A precise suturing technique with the prevention of tension and the avoidance of reduction of perfusion of the conduit (stomach, colon, small intestine) can reduce the rate of such insufficiencies. The most frequent non-surgical complication is postoperative pneumonia, which can be avoided or combated through effective pain-relieving therapy like peridural anaesthesia and specific techniques of postoperative ventilation. It is of vital importance to identify, at the earliest possible timepoint, complications that might emerge after the operation. The occurrence of postoperative tachyarrhythmia has proven to be a frequent and early indicator of such complications. The treatment of complications after oesophageal resections includes adequate conservative, interventional, e. g., endoscopic placement of a stent in cases of covered insufficiency of the suture line, and operative procedures like reoperation in cases of uncovered leakage with pleural connection. All the other surgical complications like haemorrhage, tracheobronchial leak-ages or chylothorax are rarely seen and demand specific therapeutic procedures., Conclusion: It is not only the surgery that determines a high or low complication rate in oesophageal resectional procedures. It has clearly been proved that interdisciplinary management of complications after oesophagectomy is much more effective in high-volume centres, leading to a lower mortality, than in surgical departments with a lower case rate and thus with less experience in such complex operations., (© Georg Thieme Verlag KG Stuttgart ˙ New York.)

Background: Anastomotic leaks represent the most common severe postoperative complications after esophagectomy. In this study standard inflammatory laboratory parameters [leukocytes, C-reactive protein (CRP)] were evaluated as indicators for anastomotic leakage after esophagectomy., Patients and Methods: Between 1 / 1997 and 12 / 2006 a total of 558 patients with esophageal cancer underwent an Ivor-Lewis esophagectomy. Among these patients, all those (n = 50, 8.9 %) suffering from an anastomotic leak were matched to 50 patients without anastomotic leakage. Leukocytes, CRP level and clinical parameters (body temperature, cardiac / respiratory problems, wound secretion) were retrospectively analysed at short-term intervals in both groups., Results: Patients with anastomotic leaks showed significant continuously increased CRP levels and leukocyte counts from the second or, respectively, 5 (th) postoperative day onwards compared to patients without anastomotic leaks. Using a stepwise regression, an 80 % sensitivity for leakage detection has been calculated by a cut-off value for CRP set at 13.5 mg / dL from day 2 onwards or, respectively, for leukocytes at 10.5 Gpt / L from day 8 onwards. Concomitantly, patients with anastomotic leaks suffered significantly more from respiratory problems and abdominal pain., Conclusion: CRP appears to be a reliable and predictable indicator for anastomotic leakage after esophagectomy and should, therefore, be routinely used as a screening marker to provide a reason for extended diagnosis.