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BACKGROUND: Different sites of esophageal cancer are accompanied by different regional lymph node metastasis (LNM) risks. We aimed to investigate the impact of a lower tumor margin on abdominal LNM risk. METHODS: We enrolled patients who underwent esophagectomy for esophageal squamous carcinoma (ESCC) from 2014 to 2017 in West China Hospital. Overall survival (OS) analysis was performed. We measured the distance between the lower tumor margin and esophagogastric junction (LED) with upper gastrointestinal contrast-enhanced X-ray (UGCXR). Multivariate logistic regression analysis and propensity score matching (PSM) were performed to explore the relationship between LED and the risk of abdominal LNM. Abdominal LNM risk in ESCC was stratified based on the location of the lower tumor margin. A model predicting abdominal LNM risk was constructed and presented with a nomogram. RESULTS: The included patients had an abdominal LNM rate of 48.29%. In multivariate logistic regression analysis, LED was identified as a risk factor for abdominal LNM. Subgroup analysis of middle ESCC showed that patients with an LED less than 10 cm had a significantly higher rate of abdominal LNM than those with an LED greater than 10 cm. The abdominal LNM rate in middle ESCC patients with an LED less than 10 cm was 32.2%, while it was 35.1% in lower ESCC patients whose lower tumor margin did not invade the esophagogastric junction (EGJ), which was comparable after PSM. CONCLUSIONS: LED could help surgeons evaluate the risk of abdominal LNM preoperatively and better guide dissection of abdominal lymph nodes according to risk level.

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Background: Fatigue and the long work hours of surgeons have attracted increasing concern in recent years. We aimed to explore whether starting time was associated with perioperative outcomes and cost for elective lung surgery. Methods: A retrospective study was conducted on elective lung surgery patients at a high surgery-volume center between September 2019 and November 2019. Patients were divided into the "early start group" if the surgery start time was before 4 post meridiem (pm), while the "late start group" was defined as surgery started after 4 pm. Perioperative outcomes and total hospital costs were compared between the two groups. In addition, multivariable logistic regression analysis was performed to identify whether start time was a risk factor for postoperative hospital duration, total hospital cost and length of operation time. Results: A total of 398 patients were finally enrolled for analysis in this study. Of all the cases, 295 patients were divided into the early start group, while 103 patients belonged to the late start group. Baseline characteristics were all comparable between the two groups. Concerning Regarding outcomes, there were no differences in postoperative hospital duration, operation time, complication incidence or and other outcomes, while the total hospital cost tended to be different but still not significantly different without statistical significance (P = 0.07). In multivariable logistic regression analysis, surgery starting late was still not found to be a risk factor for long postoperative hospital duration, high hospital cost and long surgery time. Conclusion: In elective lung surgery, perioperative outcomes and costs were similar between the early- and late-start groups, and it was not necessary to worry about the surgery order for these patients.

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Background: Esophageal leiomyoma is the most common benign tumor in the esophagus. Thoracotomy and thoracoscopy are both elective for esophageal leiomyoma enucleation. This study aimed at presenting surgical experience in our center and exploring more suitable surgical methods for different situations. Methods: We conducted this retrospective study by collecting data from patients who underwent esophageal leiomyoma enucleation through thoracotomy or thoracoscopy from January 2009 to November 2021 at West China Hospital Sichuan University. Results: A total of 34 patients were enrolled for analysis. All patients were diagnosed with a single esophageal leiomyoma. There were 25 men and 9 women. The mean age was 44.41 years (range, 18-72 years), the mean longest diameter was 4.99 cm (range, 1.4-10 cm), and the esophagus was thoroughly circled with leiomyoma in 10 patients, 10 patients underwent thoracotomy to enucleate leiomyoma, while others underwent thoracoscopic enucleation. No perioperative deaths occurred. Between the thoracotomy group and thoracoscopy group, baseline characteristics were comparable except for gastric tube status (p = 0.034). Patients were inclined to undergo the left lateral surgery approach (p = 0.001) and suffered esophagus completely encircled by leiomyoma (p = 0.002). Multivariable logistic regression analysis demonstrated that the left lateral surgery approach (p = 0.014) and esophagus completely encircled by leiomyoma (p = 0.042) were risk factors for thoracotomy of leiomyoma enucleation, while a larger tumor size demonstrated no risk. The median follow-up time was 63.5 months, and no deaths or recurrence occurred during the follow-up period. Conclusion: Thoracotomy enucleation of the leiomyoma was recommended when the esophagus was thoroughly encircled by the leiomyoma and the left lateral surgery approach was needed. However, tumor size demonstrated less value for selecting a surgical approach.

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The association between NSM and prognosis of esophageal cancer remains controversial, though several studies have been conducted drawing their own conclusion. Therefore, we firstly carried out this meta-analysis aiming to explore the association. We performed a comprehensive literature search online, including PubMed, Embase and Web of Science. We selected deaths at 5 years and hazard ratio (HR) with 95% (CI) to perform the meta-analysis with Review Manager 5.3, predicting value of clinic-pathological features in NSM also been analyzed. A total of 7 studies were finally enrolled in this study. NSM, defined by either JSED criterion or anatomical compartment criterion, neither showed significant prognostic value on OS of esophageal cancer (P = 0.64), (P = 0.24). Subgroup analysis of JSED criterion, NSM was not a prognostic factor in solitary node metastasis patients (P = 0.39), whereas NSM demonstrated a poor prognostic factor (P = 0.01) for ESCC. Subgroup analysis according to anatomical criterion, NSM was a favorable factor for OS in middle thoracic ESCC (P = 0.003). Pathological N1 status was found to be a risk factor for NSM (P < 0.00001) according to JSED criterion and middle thoracic ESCC was identified as a predictor for NSM (P = 0.0003) according to anatomical compartment criterion. According to JSED criterion, NSM demonstrated poor prognosis on ESCC and N1 status was a risk factor for NSM. Concerning the anatomical compartment criterion, a favorable prognosis of NSM was found in middle thoracic ESCC and NSM was prone to occur in middle thoracic ESCC. CRD42021219333.

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BACKGROUND: Venous thromboembolism remains a common but preventable complication for cancerous lung surgical patients. Current guidelines recommend thromboprophylaxis for lung patients at high risk of thrombosis, while a consensus about specific administration time is not reached. This study was designed to investigate the safety profile of preoperative administration of low-molecular-weight-heparin (LMWH) for lung cancer patients. METHODS: From July 2017 to June 2018, patients prepared to undergo lung cancer surgery were randomly divided into the preoperative LMWH-administration group (PRL) for 4000 IU per day and the postoperative LMWH-administration group (POL) with same dosage, all the patients received thromboprophylaxis until discharge. Baseline characteristics including demographics and preoperative coagulation parameters were analyzed, while the endpoints included postoperative coagulation parameters, postoperative drainage data, hematologic data, intraoperative bleeding volume and reoperation rate. RESULTS: A total of 246 patients were collected in this RCT, 34 patients were excluded according to exclusion criterion, 101 patients were assigned to PRL group and 111 patients belonged to POL group for analysis finally. The baseline characteristic and preoperative coagulation parameters were all comparable except the PRL group cost more operation time (p = 0.008) and preoperative administration duration was significantly longer (p < 0.001). The endpoints including postoperative day 1 coagulation parameters, mean and total drainage volume, drainage duration, intraoperative bleeding volume and reoperation rate were all similar between the two groups. Moreover, coagulation parameters for postoperative day 3 between the two groups demonstrated no difference. CONCLUSION: Preoperative administration of low-molecular-weight-heparin demonstrated safety and feasibility for lung cancer patients intended to receive minimally invasive surgery. TRIAL REGISTRATION: ChiCTR2000040547 ( www.chictr.org.cn ), 2020/12/1, retrospectively registered.

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BACKGROUND: The relationship between preoperative nutritional and immunological status and long-term outcome after cancerous esophagectomy has been investigated widely. Growing evidence also demonstrated preoperative nutritional and immunological status also affects short-term outcome after surgery for esophageal cancer. However, the relationship between preoperative nutritional and immunological status and short-term outcome of anastomosis-leakage patients after cancerous esophagectomy was scarce. The aim of this study was to evaluate the association between preoperative prognostic nutritional index (PNI) and short-term outcome of anastomosis-leakage patients after surgery. METHODS: In this study, we retrospectively enrolled 90 patients who were confirmed to be esophageal cancer by preoperative biopsy or postoperative pathological review and also suffered postoperative anastomotic leakage from January 2014 to June 2017 at the Department of Thoracic Surgery, West China Hospital. Then we evaluated the association between PNI and short-term surgical outcome. The endpoints included postoperative mortality, postoperative hospital duration, postoperative intensive care unit (ICU) duration, hospitalization cost. RESULTS: The cut-off value of PNI was set at 49.83 in our study, patients with a preoperative PNI ≥49.83 were divided into high-PNI group, while those with a preoperative PNI <49.83 were classified into low-PNI group. For the postoperative anastomosis-leakage patients in the two groups, baseline characteristics were all comparable, and analysis revealed no significantly statistical difference between the two groups regarding mortality, postoperative hospital duration and postoperative ICU duration. Though mean hospital-duration cost (144,791.08±87,312.87 vs. 127,364.25±69,233.16) was more in the low-PNI group, there was still no significant difference demonstrated (P=0.297). There was no significant difference revealed between the subgroups of non-death patients from the two original groups concerning the endpoints, while the hospital-duration cost of the high-PNI group tended to be lower than low-PNI group (125,262.80±71,304.12 vs. 136,421.60±77,052.49, P=0.503). CONCLUSIONS: Although in-hospital cost of high-PNI group tended to be lower than low-PNI group, preoperative PNI showed no significant prognostic value for short-outcomes of anastomosis-leakage patients after cancerous esophagectomy. More prospective studies were badly needed to provide more evidence in the future.

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BACKGROUND: Due to the threat from venous thromboembolism (VTE) after major thoracic surgery, especially for cancers, guidelines recommend either heparin sodium (unfractionated heparin) or low-molecular-weight-heparin (LMWH) for those patients at high risk of deep vein thrombosis (DVT). However, risk of bleeding remains a major concern for pre-operative administration of anti-coagulation agents. Therefore, this study aimed to compare the bleeding risk of preoperative administration of LMWH and heparin in patients undergoing video-assisted thoracic surgery (VATS) lobectomy for lung cancer. METHODS: A retrospective, single-center study was designed. A total of 130 patients diagnosed with lung cancer were included from August 2016 to January 2018. These patients were divided into two groups. The preoperative administration of heparin group (PH group) had received heparin 5,000 IU, BID (twice a day) both pre- and post-operatively. And the LMWH group (PL group) had received LMWH 4,000 IU, QD (once a day) both pre- and post-operatively. These anticoagulants would not be ceased until patient was discharged or 24-hour postoperative chest drainage volume exceeded 500 mL. Both preoperative and postoperative coagulation parameters including platelet count (PLT), hemoglobin value (HGB), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), postoperative drainage parameters and intraoperative bleeding volume were compared. RESULTS: A total of 62 patients were collected in PH group, while 68 patients comprised PL group. Preoperative coagulation parameters, hematologic data and demographic data were comparable. Preoperative duration of two agents (P=0.414), operation time (P=0.155), postoperative HGB (P=0.943), PLT (P=0.244), INR (P=0.469), PT (P=0.651), TT (P=0.407), FIB (P=0.151), drainage duration (P=0.800), duration of heparin and LMWH (P=0.778) were all comparable between the two groups. Compared with PL group, intraoperative bleeding volume (105.11 and 50.26, P<0.001) and postoperative mean drainage volume (251.52 and 216.90 mL, P=0.025) of PH group were significant more. Postoperative APTT (30.17 vs. 28.20 seconds, P=0.022) was significantly longer in PH group. CONCLUSIONS: Compared with preoperative administration of heparin, preoperative thromboprophylactic administration of LMWH significantly decreased the risk of intraoperative bleeding in VATS lobectomy.