Clinical Evaluation Of Preoperative Endoscopic Marking With Titanium Clips In Patients With Early-stage Esophageal Cancer

Part one Clinical evaluation of preoperative endoscopic marking with titanium clips in patients underwent Sweet procedure with early-stage esophageal cancerBackgroundEsophageal cancer is a common malignant tumor,and its incidence ranks the fourth among malignant tumors in China.With the development of endoscopy and the principles of cancer therapy gradually shifting to preventive interventions,early diagnosis and early treatment,an increasing number of patients with early-stage esophageal cancer were diagnosed.According to the 2009 International Union Cancer Control(UICC)classification,T1 esophageal cancer is subdivided into Tla tumor that invades lamina propria or muscularis mucosa,and T1b tumor that invades submucosa.The treatment selection for early-stage esophageal cancer is still controversial.A large retrospective study of a sample of about 5000 cases in the United States in 2014 have shown that the proportion of patients who recieved endoscopic resection for the treatment of early-stage esophageal cancer increased significantly in recent years,regardless of T1a or T1b stage.The mortality rate at 1 month after endoscopic resection was markedly reduced,but the patient's 5 year survival rate was 76.5%,which was significantly lower than that of 87.6%of the surgical patients.The study also showed that 16.6%of patients with T1b had at least 1 lymph node metastases,compared with only about 5%in Tla.Lastly,these studies stated that endoscopic resection is suitable for low-risk T1a tumor patients and T1b tumor patients should undergo standard resection of esophageal cancer unless the surgery cannot be tolerated.Patients with early-stage esophageal cancer usually present atypical clinical symptoms.A portion of patients might even have no symptom and only had local mucosal microlesions that were found by gastroscopy during a physical examination or by iodine staining,the pathology confirmed that the esophageal severe dysplasia,high level intraepithelial neoplasia,orthotopic carcinoma or squamous cell carcinoma.Barium X-Ray and CT are hard to find the tumor preoperatively,it is also difficult to touch the obvious tumor lesions,only on the basis of preoperative gastroscopy and endoscopic ultrasonography results to determine the lesion site,it brings some difficulties to the surgical operation of local lesion location.Because of its high hardness,good histocompatibility and easy operation,endoscopic titanium clips have been widely used in hemostasis and wound closure under endoscope.At present,there are many reports about preoperative and intraoperative markers for digestive tract diseases,and satisfactory results have been achieved.However,there are few clinical studies on the localization of titanium clips in endoscopic localization of early esophageal cancer,few studies are mainly applied in early esophageal cancer before radiotherapy positioning,and clinical application has not been reported in the surgery,so we need to thoracic surgery doctors for further research.ObjectiveTo explore the application value of preoperative endoscopic marking with titanium clips in patients underwent Sweet procedure for early-stage esophageal cancer.MethodsTwenty-seven patients in whom early-stage squamous cell carcinoma of esophagus or severe dysplasia was gastroscopically detected and pathologically confirmed in our hospital during the period from May 2012 to July 2014.The patients were randomly divided into the experimental group(14 cases)and the control group(13 cases).All patients in the experimental group had signed the informed consent form and the study was approved by the Ethics Committee.One day before surgery,patients in the experimental group received gastroscopy performed by the endoscopists in our hospital.In patients with prominent lesions,two titanium clips were placed on the upper and lower edges of the lesion.In patients whose lesions were not evident,the lesion was clearly identified by iodine staining first,followed by clip-marking of its upper edges.In the experimental group,2 hours after gastroscopy,the upper digestive tract was detected by meglumine contrast plate,and the location of the titanium clip was marked.A preliminary surgical approach was selected based on the preoperative endoscopic findings.The Sweet approach was adopted for all patients.For the lesions>35cm below the incisor,the surgery with an esophagogastrostomyic anastomosis below the aortic arch was performed through a left chest posterolateral incision,while for the lesion 25-35 cm below the incisor,the surgery with a supra-aortic arch esophagogastric anastomosis was performed through a left chest posterolateral incision.Results1.Preoperative results In the experimental group,14 cases were successfully labeled with titanium clips,and the location of the titanium clip in the esophagus could be accurately developed before operation,the preoperative localization rate was 100%.However,only 3 patients in the control group showed a slight stiffness in the local tube wall,and the preoperative imaging lesion location rate was 23.1%.2.intraoperative results The titanium marker clips were readily palpable after opening the mediastinal pleura in 14 patients in the experimental group.The intraoperative localization rate was 100%,In the 13 patients in the control group,except that two patients were found to have a thickened esophageal wall,tumor localization failed in the remaining 11 cases.it was only 15.3%.3.Pathological results In the experimental group,postoperative pathological examination of the specimen collected in clip-marked areas confirmed the existence of squamous cell carcinoma or severe dysplasia and the upper surgical margins negative for cancer cells in 13 patients,The pathological diagnosis rate was 92.8%in the experimental group and 92.3%in the control group.4.Choices of surgical approaches Appropriate surgical approaches were selected for all 14 patients in the experimental group based on the locations of titanium clips identified by extraluminal palpation.in the control group,after esophageaj transection using the predetermined approach,the distance between the tumor and the upper resection margin of the esophagus was found too short in 2 patients;as a result,the surgical approaches had to be changed.In one of the two patients,the esophagogastric anastomosis below the aortic arch was changed to a supra-aortic arch anastomosis,and in the other patient,the intrathoracic anastomosis was changed to a cervical anastomosis.Conclusions1.In the preoperative endoscope of the esophageal cancer,the combined upper digest:ive tract angiography can accurately position the lesion position before operation,and provide a good reference for the formulation of the surgical method.2.By preoperative endoscopic titanium clips mark,the lesion site in intraoperative touch titanium clip position accurately locate the lesion location,according to the location of the titanium clip can effectively adjust the operation method,and as far as possible to ensure enough on the upper resection margin.3.Preoperative endoscopic titanium clips mark not only provides a reliable basis for postoperative accurate pathological diagnosis,but also provides an accurate basis for the measurement of the upper resection margin.Part two Clinical evaluation of preoperative endoscopic marking with titanium clips in patients underwent Minimally invasive IVOR-Lewis and McKeown procedures with early-stage esophageal cancerBackgroundIn recent years,with the rapid development of TV chest-laparoscopic techniques,Department of thoracic surgery also entered the era of minimally invasive surgery,compared with minimally invasive surgery of lung,esophageal cancer surgery start slowly,the operation is difficult,especially for Department of thoracic surgery physicians master laparoscopic technique,but in recent years,more and more treatment center for minimally invasive surgery esophageal surgery,the surgery is the most common minimally invasive IVOR-Lewis and McKeowm surgery.Compared with the traditional open chest surgery,minimally invasive surgery has small trauma,less bleeding,rapid recovery,and the right chest I.VOR-Lewis and McKeowm surgery is more consistent with the normal anatomical position of the esophagus,but also has a lower complication rate and more lymph node biopsy rate.Early esophageal cancer is more suitable for minimally invasive surgery than open surgery.Since minimally invasive esophageal surgery does not have a large incision in the chest,it is not possible to locate the lesion by hand touch,so it is more difficult to locate in surgery than open surgery.Our department began to use minimally invasive esophageal surgery for early cancer patients in July 2015,using preoperative endoscopic titanium clips mark the location of the lesion,and explore its surgical value.ObjectiveTo explore the application value of preoperative endoscopic marking with titanium clips in patients underwent Minimally invasive procedure for early-stage esophageal cancer.MethodsA retrospective analysis from July 2015 to March 2017 IVOR-Lewis and McKeowm of minimally invasive surgical treatment of 41 patients with early esophageal cancer patients in Tai'an Central Hospital,one day before surgery,patients received gastroscopy performed by the endoscopists in our hospital.In patients with prominent lesions,two titanium clips were placed on the upper and lower edges of the lesion.In patients whose lesions were not evident,the lesion was clearly identified by iodine staining first,followed by clip-marking of its upper The position of titanium clip in the esophageal cavity was accurate in the upper gastrointestinal tractand lower edges.Two hours after gastroscopy,patients underwent upper gastrointestinal tract radiography(using meglumine diatrizoate as the contrast agent)to confirm the location of titanium clips.According to gastroscopy and upper gastrointestinal radiography results,lesion distance below 25cm or incisor titanium clip below is located in the carina underwent minimally invasive IVOR-Lewis procedure,lesion distance 25cm incisors above or above the carina with titanium clip underwent the minimally invasive McKeowm procedure.Including IVOR-Lewis surgery group 25 cases,McKeowm surgery group 16 cases,were compared between the two groups the general clinical data,accurate positioning,surgical and pathological data.ResultsTwo groups of patients were successfully labeled with titanium clips,the location of titanium clip in the esophageal cavity was accurate in the upper digestive tract;IVOR-Lewis group 25 patients were unable to confirm the lesion site during the operation of the thoracoscopic free esophagus,also unable to touch the wall to determine the location of the titanium clips,but before placing the top of the stapled device,the preoperative titanium clip can be seen in the cutting open esophageal cavity,and the accuracy of localization is 100%.McKeowm 16 patients were also able to see the titanium clips after cutting the esophagus at the neck,the accuracy of localization is 100%.The two groups of patients were completed according to the preoperative method of surgery,the pathological diagnosis rate was 100%,and the upper margin negative rate was 100%.Conclusions1.combined with upper gastrointestinal radiography,preoperative endoscopic localization of the lesion and the location of the upper gastrointestinal tract in early esophageal cancer can accurately localize the lesion and provide the basis for selecting a reasonable minimally invasive surgical approach.2.,because it is difficult to touch the location of the lesion or the location of the titanium clip,it is the fastest and accurate method to open the esophagus and explore the titanium clip.It is also the main basis to ensure the negative margin of the upper margin.3.titanium clip mark also provides reliable basis for the rapid and accurate diagnosis of disease in the pathology department.4.Minimally invasive IVOR-Lewis and McKeowm have advantages and disadvantages,and it is very important to choose the appropriate surgical method according to the location of the lesion and the proficiency of the operator.