Chylothorax is a relatively rare complication after surgery of the mediastinum. The occurrence and the results of surgical treatment of this condition are difficult to foresee due to the wide ...heterogeneity in thoracic duct anatomy.
We report two cases of postoperative chylothorax treated with ligation by video-assisted thoracoscopic surgery (VATS). The first patient developed a massive left chylothorax shortly after discharge, following radical excision of a seminoma-involved left para-aortic lymphadenopathy. The second patient developed a high-output right chylothorax following VATS upper bilobectomy. In both cases, a surgical revision by VATS was performed. Inguinal injection of indocyanine green allowed an easy visualization of the lymphatic leakage point. In both cases, oral feeding was rapidly restarted after surgery. No recurrence of chylothorax was observed.
The use of indocyanine green may greatly improve the identification of the thoracic duct during surgical ligation by VATS, with a favorable impact on the postoperative course and overall admission costs.
To explore the feasibility and efficacy of a dose intensification with Intensity Modulated Radiation Therapy and Simultaneous Integrated Boost (IMRT-SIB) in locally advanced esophageal and ...gastroesophageal cancer (GEJ).
We retrospectively analyzed a series of 69 patients with esophageal or GEJ cancer treated at our Institute, between 2016 and 2019, with preoperative IMRT and SIB up to 52.5-54 Gy in 25 fractions in 5 weeks and concurrent carboplatin (AUC2) and paclitaxel (50 mg/m
), as in the CROSS regimen.
All patients completed the planned IMRT-SIB program with a median of four (range 1-5) cycles of concurrent paclitaxel/carboplatin. Compliance to IMRT-SIB was 93%, whereas 54% of patients received four to five cycles and 87% at least three cycles of concurrent carboplatin/paclitaxel. Grade 3 toxicity was reported in 19% of patients. Complete clinical response (cCR) was achieved in 48%, and 13% had disease progression after chemoradiation (CRT). Overall, 49% of patients underwent surgery; reasons for non-operation included cCR in cervical tumor location (10%) or cCR and patient decision (13%). A pathologic complete response (pCR) was achieved in 44% of resected patients. Postoperative complications and mortality rates were 21 and 6%, respectively. At a median follow-up of 12 months (6-25), 2-year overall and progression-free (PFS) survival rates were 81 and 54%, respectively. No difference in PFS by histologic type in operated patients was reported. Non-operated cCR patients had higher PFS, including cervical locations and selected cCR patients who decided for non-operation (75
30%, p < 0.01).
The study reported favorable results in safety and feasibility of the IMRT-SIB dose intensification in our preoperative CRT program. The toxicity was acceptable, allowing a high compliance to intensified radiation doses with dose reduction of concurrent paclitaxel/carboplatin in some patients. The high rate of cCR and pCR suggested this intensified program is effective in the preoperative CRT and, for selected responsive patients, in the non-operative approach to esophageal and GEJ cancer. The 2-year survival rates were promising. A prospective study is being planned to confirm these observations.
Chylothorax is a serious complication of transthoracic esophagectomy. Intraoperative thoracic duct (TD) identification represents a possible tool for preventing or repairing its lesions, and it is ...most of the time difficult, even during high-definition thoracoscopy. The aim of the study is to demonstrate the feasibility of using near-infrared fluorescence-guided thoracoscopy to identify TD anatomy and check its intraoperative lesions during minimally invasive esophagectomy. A 0.5 mg/kg solution of indocyanine green (ICG) was injected percutaneously in the inguinal nodes of 19 patients undergoing minimally invasive esophagectomy in a prone position, before thoracoscopy. TD anatomy and potential intraoperative lesions were checked with the KARL STORZ OPAL1® Technology. In all of the 19 patients where transthoracic esophagectomy was feasible, the TD was clearly identified after a mean of 52.7 minutes from injection time. The TD was cut for oncological radicality in two patients, and it was successfully ligated under the ICG guide. No postoperative chylothorax or adverse reactions from the ICG injection occurred. The TD identification with indocyanine green fluorescence during minimally invasive esophagectomy is a simple, effective, and non-time-demanding tool; it may become a standard procedure to prevent postoperative chylothorax.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Skeletal muscle in patients with cancer undergoes many morphological changes due to immuno-inflammatory factors of tumor origin or treatment.T he latest event of these changes is cancer cachexia. Aim ...of the study is to identify myopathic features in skeletal muscle biopsies from weight stable patients with colorectal cancer and without cachexia or asthenia / weakness, that could possibly provide new diagnostic and prognostic cancer biomarkers. Morphometric analyses and immunohistochemical studies were performed on intraoperative muscle biopsies from patients with colorectal cancer and from weight stable patients undergoing surgery for benign non-inflammatory conditions. A rectus abdominis biopsy was taken in all patients and controls.A correlation between histopathologic findings and clinical characteristics, circulating inflammatory biomarkers and markers of muscle necrosis,surgery data and cancer phenotype were investigated.. Forty four patients (21male/23 female) and 17 controls (6 male/11 female) (p=NS) were studied. In cancer patients'biopsies we observed asubclinical myopathy characterized by an abnormal distribution of myonuclei, which are localized inside the myofiber rather than at the periphery, and by the presence of regenerating muscle fibers. The percentage of myofibers with internalized nuclei is significantly higher in patients (median= 9%, IQR= 3.7-18.8) than in controls (median= 2.7%, IQR= 1.7-3.2) ( p=0.0002). In patients we observed an inverse correlation between the number of centronucleated fibers and the presence of node metastasis (N+)(ρ)=-0.64 (p=0.002). Patients affected with colorectal cancer display early sign of a myopathy, characterized by centronucleated and regenerating myofibers. This myopathy appears to be associated with an early stage of neoplasia and it could be an adaptive response of muscle to cancer. We hope a future application of these findings as a possible early diagnostic and prognostic biomarker of neoplasia.
e16110 Background: The optimal management of locally advanced gastroesophageal junction adenocarcinoma (LAGEJad) is not fully established yet. Both neoadjuvant chemoradiotherapy (CRT) and ...perioperative taxane-based triplet chemotherapy (CT) are acknowledged treatment options for Siewert I and II cancers. In this retrospective study, we aimed to assess the safety and outcomes of an intensified preoperative regimen combining taxane-based triplet CT and CRT. Methods: We conducted a retrospective analysis of a cohort comprising 16 consecutive HER2 negative patients (pts) with LAGEJad treated at the Centro di Riferimento Oncologico of Aviano between 2019 and 2022. All pts received induction CT (iCT) consisting of fluoropyrimidine, oxaliplatin and docetaxel, followed by CRT (45Gy/25Fr) with simultaneous boost and concomitant CT. Surgery (Ivor-Lewis or McKeown) was performed 8 weeks post-CRT. Clinico-pathological (CP) and treatment features were analyzed using logistic regression to assess their association with response to iCT-CRT. The association of iCT-CRT with survival outcomes was investigated using the Kaplan-Meier method. Results: Key CP data are summarized in Table 1. Median age was 59 years, all pts were male. At diagnosis, 81.2% of pts exhibited cT3+ and cN+ disease. All pts received iCT and CRT. The rate of partial responses was 50% after iCT and 68.8% after CRT. Overall, 12 pts underwent surgery, all achieving R0 resections within a median timeframe of 9 8.5;11 weeks post-CRT. Among them, 25% had a pathologic complete response, while 62.5% attained a Mandard tumor regression grade (TRG) of 1-2. No new safety signals emerged from iCT (only 2 pts had ≥G3 diarrhea) or CRT (≥G3 mucositis occurred in 6.2% and anemia in 6.2% of pts). No significant surgical delays were observed, although 5 pts experienced post-operative complications (4 grade I, 1 grade IIa). There were no statistically significant associations between CP variables and response to the iCT-CRT. Relapses were seen in 8 pts (2 locoregionally); 3-year survival was 46%. Median event-free survival was 5 5;11 months, while median overall survival 34 14;NR months. Conclusions: The intensification of preoperative treatment in pts with LAGEJad is active and safe: the surgical schedule was not significantly delayed, and the safety profile remained comparable to standard regimens, with no major complications reported. Randomized clinical trials are ongoing to assess the clinical benefits of this approach. Table: see text
Abstract
Pulmonary complications (PPC) are still reported in 30% of patients also after minimally-invasive esophagectomy in high volume centers. 1–2.
Prehabilitation programs are promising in ERAS ...protocols. 3 Open esophagectomy (OE) has the lowest anastomotic leakage rate but higher PPC.4,5.
The combination of pre-habilitation and the application of High-Flow Nasal Cannula (HFNC) after OE has not been investigated yet.
This is a feasibility study evaluating a pre-habilitation program and the post-operative application of HFNC on PPC after OE.
We prospectively included patients undergoing OE from May 2021 to February 2022.
A preoperative multimodal prehabilitation program was applied to all patients.
Within 4 hours after surgery, patients were extubated and put under HFNC (50–60 lt/min with FIO2 0.4, humidifier temperature at 34°C) for the following 5 days. Chest physiotherapist applied daily post-operative respiratory exercise to all patients.
Hospital stay outcomes, feasibility of HFNC and PPC were recorded by 30 days after surgery.
We compared this group with an historic cohort (January 2016–March 2021) where HFNC was not applied to determine differences in baseline characteristics and post-operative complications.
We included 45 patients for the final analysis, 12 in the HFNC and 33 in the historic cohort. Baseline characteristics comparisons are shown in table 1.
No interruption of post-operative HFNC was recorded due to patient’s complain.
PPC in the two groups were statistically comparable. No adverse event was related to HFNC application. The overall leakage rate was 9%.
A prehabilitation program and HFNC use after OE seems feasible, safe and well tolerated by patients.
PPC were lower in the treatment group without statistically significant difference. Pneumonia was recorded in less than 20% of patients; in the study group there weren’t severe pulmonary complications (ARDS, reintubations).
HFNC looks like an interesting tool for post-operative respiratory support.
Larger randomized controlled trials should be designed to evaluate HFNC efficacy after esophagectomy.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Malignant perivascular epithelioid cell tumor (PEComa) is a rare tumor composed of hybrid tumor cells characterized by immunoreactivity for both melanocytic and smooth muscle markers. This paper ...describes the uncommon esophageal location of an 8 cm PEComa in a 75-year-old Caucasian man who was presented with ingravescent dysphagia. Although PEComas arising within the gastrointestinal tract are exceptional findings, clinicians should not exclude this class of tumors in the diagnostic investigation of a bulky lesion of the esophageal wall.
Abstract
Background
Minimally invasive esophagectomy (MIE) has been met with increased interest for the surgical treatment of esophageal cancer. One critical obstacle for the implementation of MIE ...has been the intrathoracic anastomosis. In this study, we describe a technique of Ivor Lewis MIE in prone position and we present the short-term outcomes of this procedure compared to the McKeown MIE.
Methods
A total of 53 consecutive patients with with an Adenocacinoma of the gastroesophageal junction (GEJ) or the distal esophagus esophageal who had undergone MIE were included in the analysis. The clinical outcomes were analized and compared between the 24 patients treated with thoracoscopic two field Ivor Lewis (IL) MIE with intrathoracic stapled End-to-side anastomosis and 29 patients treated with thoracoscopic three field McKeown (McK) MIE with cervical stapled End-to-side anastomosis. The main outcome was postoperative respiratory complications. The secondary outcomes included the length of the operation, blood transfusion, number of dissected lymph nodes, postoperative morbidities and mortality.
Results
No statistical difference was found between postoperative respiratory complications (p: 0, 475), operative time (p: 0395), Lymph node retrieved (p: 0864), blood transfusion (p: 0951), ICU stay (p: 0131), oral intake in days (p: 0592), post operative stay (p:0830), anastomotic leakage (p: 0669), overall morbidity (p:0400), mortality (p: 0267). Anastomotic stenosis were more frequent in the McKeown group (p: 0062).
Conclusion
The intrathoracic stapled end-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.
Disclosure
All authors have declared no conflicts of interest.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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