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Background An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. Methods The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. Discussion The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. Trial registration NCT03222895 , date of registration: July 19th, 2017.

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throughout the follow-up period the child has demonstrated evidence of ongoing neurologic improvement.This represents the youngest reported patient to be supported successfully to transplant with the PediMag pump. In addition, the PediMag was later used as posttransplant ECMO support in combination with the QUADROX-iD oxygenator. When using ¼-inch tubing connections with minimal length, the priming volume of the ECMO circuit is less than 160 mL, and the cannulas are readily available and easy to implant. Thrombotic complications continue to plague mechanical assistance in this age group, highlighting the importance of ongoing vigilance for areas of turbulence or stasis while the patient is receiving device support. In light of this, we endorse the use of coated tubing, connectors, and cannulas, and we prefer to limit the complexity of the circuit where possible. Relative to our previous mechanical circulatory assist experience in children 3 with the CentriMag (Thoratec Corporation, Pleasanton, Calif) at low flow, we have found the PediMag to be less prone to thrombus while being comparably easy to implant and use postoperatively.