Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009;137:587-595; discussion 596. [PMID: 19258071 DOI: 10.1016/j.jtcvs.2008.11.042]

Adjuvant chemotherapy for patients with pathologic node-positive esophageal cancer after induction chemotherapy is associated with improved survival

OBJECTIVES

The study objectives were to identify variables associated with the use of adjuvant chemotherapy among patients with node-positive esophageal cancer who received induction therapy and to evaluate its relationship with overall survival.

METHODS

Treatment data for patients with esophageal cancer receiving induction chemotherapy ± radiotherapy and esophagectomy were abstracted from the National Cancer Data Base. Pathologic node-positive patients were dichotomized by whether they received 2 or more cycles of adjuvant chemotherapy or none. Kaplan-Meier survival curves were generated, and a Cox proportional hazards model was done to identify factors associated with overall survival.

RESULTS

From 2006 to 2012, 3100 patients had pathologic positive nodes after induction therapy and esophagectomy. A total of 2625 patients (84.7%) did not receive adjuvant chemotherapy, and 475 patients (15.3%) did. N3 nodal stage was associated with an increased likelihood of receiving adjuvant chemotherapy (reference: N1, odds ratio, 1.82, 95% confidence interval, 1.15-2.97, P = .01), whereas increasing age (by year, odds ratio, 0.97, confidence interval, 0.96-0.98, P < .001), induction chemoradiation therapy (reference: induction chemotherapy, odds ratio, 0.39, confidence interval, 0.30-0.52, P < .001), and increasing inpatient length of stay after esophagectomy (per day: odds ratio, 0.98, confidence interval, 0.97-0.99, P = .007) were associated with a decreased likelihood. Patients receiving adjuvant chemotherapy had improved overall survival at each pathologic nodal stage: 31.6 months versus 22.7 months for N1 disease (P < .001), 32.4 months versus 19.2 months for N2 disease (P = .035), and 19.5 months versus 10.4 months for N3 disease (P < .001). Adjuvant therapy was independently associated with decreased mortality hazard (hazard ratio, 0.69, 95% confidence interval, 0.57-0.83, P < .001).

CONCLUSIONS

Patients receiving adjuvant chemotherapy after induction therapy and esophagectomy show a survival benefit at all positive nodal stages. Prospective studies may help further delineate this benefit.

Long-Term Survival and Tumor Recurrence in Patients with Superficial Esophageal Cancer after Complete Non-Curative Endoscopic Resection: A Single-Center Case Series

Background/Aims

To report the long-term survival and tumor recurrence outcomes in patients with superficial esophageal cancer (SEC) after complete non-curative endoscopic resection (ER).

Methods

We retrieved ER data for 24 patients with non-curatively resected SEC. Non-curative resection was defined as the presence of submucosal and/or lymphovascular invasion on ER pathology. Relevant clinical and tumor-specific parameters were reviewed.

Results

The mean age of the 24 study patients was 66.3±8.3 years. Ten patients were closely followed up without treatment, while 14 received additional treatment. During a mean follow-up of 59.0±33.2 months, the 3- and 5-year survival rates of all cases were 90.7% and 77.6%, respectively. The 5-year overall survival rates were 72.9% in the close observation group and 82.1% in the additional treatment group (p=0.958). The 5-year cumulative incidences of all cases of recurrence (25.0% vs. 43.3%, p=0.388), primary EC recurrence (10.0% vs. 16.4%, p=0.558), and metachronous EC recurrence (16.7% vs. 26.7%, p=0.667) were similar between the two groups.

Conclusions

Patients with non-curatively resected SEC showed good long-term survival outcomes. Given the similar oncologic outcomes, close observation may be an option with appropriate caution taken for patients who are medically unfit to receive additional therapy.

The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review

BACKGROUND

The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery.

METHODS

A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed.

RESULTS

A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery.

CONCLUSIONS

The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.

Staging resection of multiple primary esophageal cancer by endoscopic submucosal dissection and esophagectomy: A case report

RATIONALE

Multiple primary esophageal cancer pose great risks to patients and are always challenging to resect surgically. In order to reduce the risk of postoperative complication and meet the needs of minimally invasive and precision medicine, new treatment plans have been always developed for patients with multiple primary esophageal cancer.

PATIENT CONCERNS

A 75-year-old man was admitted to our hospital for aggravated dysphagia. No significant abnormalities were identified on physical examination.

DIAGNOSES

Endoscopic examination detected 3 masses in the esophagus and biopsy confirmed multiple primary esophageal cancer.

INTERVENTION

The patient received a new staging treatment procedure firstly and an innovative single-position, minimally invasive Ivor Lewis esophagectomy in our hospital.

OUTCOMES

This patient discharged one week after the surgery and enjoyed a good health during our follow up for 30 month.

LESSONS

We believe our procedure provides a beneficial new alternative approach for patients with multiple primary esophageal cancer.

Towards optimal intraoperative conditions in esophageal surgery: A review of literature for the prevention of esophageal anastomotic leakage

BACKGROUND

Esophageal anastomotic leakage (EAL) is a severe complication following gastric and esophageal surgery for cancer. Several non-modifiable, patient or surgery related risk factors for EAL have been identified, however, the contribution of modifiable intraoperative parameters remains undetermined. This review provides an overview of current literature on potentially modifiable intraoperative risk factors for EAL.

MATERIALS AND METHODS

The PubMed, EMBASE and Cochrane databases were searched by two researchers independently. Clinical studies published in English between 1970 and January 2017 that evaluated the effect of intraoperative parameters on the development of EAL were included. Levels of evidence as defined by the Centre of Evidence Based Medicine (CEBM) were assigned to the studies.

RESULTS

A total of 25 articles were included in the final analysis. These articles show evidence that anemia, increased amount of blood loss, low pH and high pCO2 values, prolonged duration of procedure and lack of surgical experience independently increase the risk of EAL. Supplemental oxygen therapy, epidural analgesia and selective digestive decontamination seem to have a beneficial effect. Potential risk factors include blood pressure, requirement of blood products, vasopressor use and glucocorticoid administration, however the results are ambiguous.

CONCLUSION

Apart from fixed surgical and patient related factors, several intraoperative factors that can be modified in clinical practice can influence the risk of developing EAL. More prospective, observational studies are necessary focusing on modifiable intraoperative parameters to assess more evidence and to elucidate optimal values of these factors.

Is Esophagectomy for Benign Conditions Benign?

BACKGROUND

Outcomes data on esophagectomy performed for benign conditions is scarce. Using the National Surgical Quality Improvement Program database, we sought to analyze outcomes of esophagectomy performed for benign conditions.

METHODS

The National Surgical Quality Improvement Program database was queried for all esophagectomies performed from 2005 to 2015. Outcomes for benign conditions were analyzed and compared with outcomes for malignant conditions.

RESULTS

Esophagectomy was performed in 7,477 patients during the study period. Of those, 6,762 underwent esophagectomy for malignant conditions and 715 for benign conditions. For patients with benign conditions, reconstruction was performed using gastric conduit in 631 and colon/intestine in 84. The anastomosis was intrathoracic in 420 and cervical in 295. Benign esophagectomies were more likely to be emergent (10.1% vs 0.4%, p < 0.001). In addition, these patients had a longer hospital length of stay (17.2 days vs 14.5 days, p < 0.001) and higher occurrence of Clavien-Dindo grade IV complications (25% vs 20%, p = 0.003). Mortality was similar at 4%. In patients with benign conditions, reconstruction with colon/intestine had higher occurrence of Clavien-Dindo Grade IV complications (37% vs 23%, p = 0.006), surgical wound infections (33% vs 16%, p < 0.001), and death (10% vs 4%, p = 0.017) compared with gastric reconstruction. Site of anastomosis did not affect outcomes.

CONCLUSIONS

Benign esophagectomies are associated with significant morbidity. Although the site of the anastomosis does not alter outcomes, use of colon/intestine conduit should be pursued with caution.

Racial Disparity in Utilization of High-Volume Hospitals for Surgical Treatment of Esophageal Cancer

BACKGROUND

Utilization of high-volume hospitals (HVH) for esophagectomy has been associated with improved perioperative outcomes and reduced mortality. We aimed to test the hypothesis that black-white racial disparities exist in HVH utilization and identify predictors of in-hospital surgical outcomes of esophageal cancer while adjusting for HVH utilization patterns.

METHODS

We queried the New York Statewide Planning and Research Cooperative System database (1995 to 2012) for esophageal cancer patients who underwent surgical resection exclusively. Only records for patients with self-reported white or black race and a valid New York State ZIP code were included (n = 2,895). Analysis was performed to identify factors associated with HVH hospital (≥20 esophagectomies/year) utilization and determine predictors of complications and in-hospital mortality.

RESULTS

Black patients (361 [12.5%]) were significantly different (p < 0.001) than their white counterparts in the proportion of women, Medicaid, income distribution, and privately insured individuals. Although 55% patients overall utilized an HVH, blacks were significantly less likely to utilize an HVH than whites (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.14 to 0.24), even though 74.5% resided within 8.9 miles of one. Operations performed at HVHs were associated with lower in-hospital mortality (OR, 0.48; 95% CI, 0.35 to 0.65); however, mortality remained higher for blacks (OR, 2.04; 95% CI, 1.65 to 3.30; propensity matched OR, 2.45; 95% CI, 1.5 to 4.03).

CONCLUSIONS

Black patients were less likely to undergo esophagectomy at an HVH and experienced higher mortality. Efforts should be made to understand factors influencing patients' decision process and improve referral practices to ensure optimal care is provided across all segments of the population, irrespective of race, insurance, or income status.

Extracorporeal membrane oxygenation to facilitate tracheal healing after oesophagogastric catastrophe

Anastomotic leak after oesophagectomy is associated with poor outcomes. We report the successful utilization of venovenous extracorporeal membrane oxygenation in conjunction with tracheal stent to treat and heal multiple tracheal-neo-oesophageal fistulae following oesophagectomy.

Preoperative Glycosylated Hemoglobin Levels Predict Anastomotic Leak After Esophagectomy with Cervical Esophagogastric Anastomosis

BACKGROUND

Patients with diabetes are considered at increased risk of delayed wound healing and infectious complications, yet the relationship between diabetes and anastomotic leak (AL) remains unclear. Given that glycosylated hemoglobin (HbA1c) is a validated indicator of the long-term glycemic state, we evaluated the relationship between preoperative HbA1c levels and AL after esophagectomy.

METHODS

We assessed 300 consecutive patients who underwent esophagectomy reconstructed with cervical esophagogastric anastomosis between 2011 and 2015. HbA1c levels were measured within 90 days before esophagectomy. We performed comparison between the patients with and without diabetes. In addition, the predictive factors for AL, as well as the relationship between HbA1c levels and AL, were investigated.

RESULTS

Among the 300 patients, 35 had diabetes. The overall prevalence of AL was 11.7%, and patients with diabetes had a higher prevalence of AL than those without (p = 0.045). In univariate analysis, we identified diabetes, HbA1c level, and hand-sewn anastomosis as risk factors for AL significantly (p = 0.033, 0.009, and 0.011, respectively), but we also found previous smoking history, chronic hepatic disease, and supracarinal tumor location also showed tendencies to be risk factors (p = 0.057, 0.055, and 0.064, respectively). Multivariate logistic regression analysis indicated that chronic hepatic disease (p = 0.048), increased HbA1c level (p = 0.011), and hand-sewn anastomosis (p = 0.021) were independent risk factors for AL.

CONCLUSIONS

Preoperative HbA1c level was significantly associated with the development of AL after cervical esophagogastric anastomosis. We recommend preoperative HbA1c screening for all patients scheduled to undergo esophagectomy.

Oesophageal cancer

Oesophageal cancer is a clinically challenging disease that requires a multidisciplinary approach. Extensive treatment might be associated with a considerable decline in health-related quality of life and yet still a poor prognosis. In recent decades, prognosis has gradually improved in many countries. Endoscopic procedures have increasingly been used in the treatment of premalignant and early oesophageal tumours. Neoadjuvant therapy with chemotherapy or chemoradiotherapy has supplemented surgery as standard treatment of locally advanced oesophageal cancer. Surgery has become more standardised and centralised. Several therapeutic alternatives are available for palliative treatment. This Seminar aims to provide insights into the current clinical management, ongoing controversies, and future needs in oesophageal cancer.

Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk

BACKGROUND

In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation.

METHODS

We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS).

RESULTS

In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001).

CONCLUSIONS

In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.

Transhiatal vs. Transthoracic Esophagectomy: A NSQIP Analysis of Postoperative Outcomes and Risk Factors for Morbidity

BACKGROUND

Both transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are accepted procedures for esophageal resection. We aimed to compare postoperative outcomes between these procedures and identify risk factors for morbidity.

METHODS

A retrospective analysis was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent THE or TTE between 2005 and 2014 were included. Postoperative morbidity, length of stay, and 30-day mortality were compared. Multivariable logistic regression was used to determine risk factors for complications, and likelihood ratio tests were used to assess whether the effect of each risk factor was different across THE and TTE.

RESULTS

A total of 4053 patients were included, 2362 (58.3%) underwent TTE and 1691 (41.7%) underwent THE. TTE was associated with higher incidences of postoperative pneumonia and bleeding requiring transfusion. THE had higher incidences of superficial wound infection, deep wound infection, urinary tract infection, and sepsis. There were no significant differences in occurrence of anastomotic leak (THE 7.6% vs. TTE 9.4%, p = 0.35) or 30-day mortality (THE 2.3% vs. TTE 2.5%, p = 0.63). Female gender, black race, hypertension, diabetes, chronic obstructive pulmonary disease, partially or fully dependent functional status, and an ASA score ≥ 3 were independently associated with postoperative complications. The impact of the risk factors on morbidity was similar across both procedures.

CONCLUSIONS

THE and TTE have similar incidence of anastomotic leak and 30-day mortality. The impact of gender, race, and patients' comorbidities on postoperative complications is similar across both types of esophagectomy.

C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis

Background

Anastomotic leak is one of most significant causes of mortality after esophagectomy. Therefore, it is clinically valuable to detect anastomotic leak early after esophagectomy in esophageal cancer. The purpose of this study is to investigate the associations between routine postoperative laboratory findings and anastomotic leak and to analyze the laboratory findings to find out an independent predictive marker for anastomotic leak. In addition, this study compares cases treated with neoadjuvant therapy (NT) and those without (non-NT).

Methods

We retrospectively assessed the medical records of 201 consecutive cases that met this study's criteria from January 2009 to December 2016. All patients underwent curative and complete esophagectomy for intra-thoracic esophageal cancer. We compiled and analyzed routine laboratory findings from the day before surgery to the eighth postoperative day on a daily basis. Routine laboratory tests consisted of 26 separate tests, including complete blood cell counts, blood chemistries, as well as erythrocyte sedimentation rate and C-reactive protein (CRP). Barium esophagogram with chest computed tomography (CT) was performed on the seventh postoperative day to evaluate the presence of an anastomotic leak.

Results

A total of 45 of 201 patients underwent NT. Anastomotic leaks were found in 23 (11.4%) of 201 patients (8 patients in NT and 15 patients in non-NT). White blood cell (WBC) from the second postoperative day (P=0.031, P=0.006, P=0.007, P=0.007, P=0.041, and P=0.003, respectively) and CRP from the third postoperative day (P=0.012, P<0.001, P=0.014, P<0.001, P=0.001, and P=0.006, respectively) were associated with anastomotic leak in non-NT; however, only CRP on the third, fifth, sixth, and seventh postoperative days (P=0.041, P=0.037, P=0.002, and P=0.003, respectively) was associated with anastomotic leak in NT. The CRP level on the third postoperative day was a significant independent predictive marker of anastomotic leak (P=0.041, odd ratio (OR) 1.056, 95% confidential interval (CI): 1.002-1.113) and had a significant diagnostic cutoff value for the development of anastomotic leak (non-NT: cutoff value 17.12 mg/dL, sensitivity 69.2%, specificity 78.1%, P<0.001, area 0.822; NT: cutoff value 16.42 mg/dL, sensitivity 80.0%, specificity 70.0%, P=0.042, area 0.7104).

Conclusions

There were divergent laboratory findings reflective of anastomotic leak between patients who underwent NT and those who did not. The CRP level on the third postoperative day had a significant cutoff value for early detection of anastomotic leak after esophagectomy in both NT and non-NT groups.

Comparison of perioperative outcomes following hybrid minimally invasive versus open Ivor Lewis esophagectomy for esophageal cancer

BACKGROUND

The outcomes of various minimally invasive esophagectomy (MIE) procedures for esophageal cancer have been reported; however, those of the hybrid approach are lacking. This study aimed to assess the impacts of hybrid minimally invasive Ivor Lewis esophagectomy (HIL, laparoscopy and right thoracotomy) for esophageal cancer on perioperative outcomes compared with the open approach.

METHODS

This was a retrospective study of 153 patients who underwent Ivor Lewis esophagectomy for squamous cell carcinoma between January 2008 and December 2016. Patients who received neoadjuvant treatment prior to surgery (n=22) and underwent complete minimally invasive procedures (n=16) were excluded. Clinical characteristics and perioperative outcomes of patients who underwent HIL (n=53) were compared with findings in patients who underwent open Ivor Lewis esophagectomy (OIL, n=62).

RESULTS

There were 112 men (97.4%) and 3 women (2.6%) with a median age of 66 years (range, 45-83 years). The HIL and OIL groups were comparable with respect to age, sex, preoperative pulmonary function, location of the tumor, and preoperative laboratory findings. There was no significant difference between the two groups regarding surgical data, except for pyloric management. Postoperative complications occurred in 17 (32.1%) and 23 (37.1%) patients in the HIL and OIL groups, respectively (P=0.573); in-hospital mortality rates were 3.8% and 8.1%, respectively (P=0.337). HIL group patients had higher albumin (3.3 vs. 2.9 g/dL; P<0.001) and lower C-reactive protein (6.4 vs. 8.1 mg/L; P<0.001) postoperatively. The length of hospital stay was shorter in the HIL group (13.5 vs. 19.2 days; P=0.002).

CONCLUSIONS

Compared with the conventional open approach, HIL for esophageal cancer showed better postoperative nutritional and inflammatory status, resulting in shorter hospital stays. However, further studies are required to evaluate the long-term oncologic outcomes of this hybrid approach.

Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer

BACKGROUND

An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer.

METHODS

Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel).

RESULTS

Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients.

CONCLUSIONS

Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.

Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid "Lewis Santy"

BACKGROUND AND STUDY AIMS

Esophagogastric anastomosis (EGA) has a high risk of leakage. Based upon our experience in endoscopic gastrojejunal anastomosis using LAS, the aim of this study was to verify the technical feasibility and the safety of performing an EGA using a hybrid approach (endoscopic and surgical).

MATERIALS AND METHODS

A pilot prospective study was performed on 8 survival pigs. The procedure was carried out in 2 stages: (i) surgical step consisting of an esogastrectomy by laparotomy with separated suture of the esophagus and stomach; (ii) endoscopic esophagogastric anastomosis using the LAS. The first 2 pigs allowed for the setting of the 2 steps procedure, and 6 were included in the study for assessing the efficacy and safety of the procedure with a 3-week survival course. The primary endpoint was morbidity and mortality.

RESULTS

All procedures were successfull. The mean operative time was 98 minutes, with a mean endoscopic time of 46 minutes. Three early deaths occurred within the first weeks, unrelated to the LAS anastomosis. At 3 weeks, endoscopic assessment followed by necropsy demonstrated the right position and the endoscopic removability of the stent with good patency of the esophagogastric anastomosis, without leakage of the endoscopic suture. Pathological examination confirmed the patency of the anastomosis with fusion of mucosal and muscle layers.

CONCLUSION

Endoscopic esophagogastric anastomosis with LAS is feasible and reproducible, without anastomotic leakage. It could be a new alternative to perform safe anastomoses, as part of a hybrid approach (surgical and endoscopic).

Prognostic Impact of Postoperative Complications in 502 Patients With Surgically Resected Esophageal Squamous Cell Carcinoma: A Retrospective Single-institution Study

OBJECTIVE

To investigate the relationship between postoperative complications and long-term survival in patients with surgically resected esophageal squamous cell carcinoma (ESCC).

SUMMARY BACKGROUND DATA

Esophagectomy is the mainstay of curative treatment for ESCC; however, this complex procedure has high risks of postoperative morbidity and mortality. The impact of postoperative complications on long-term survival of such patients remains controversial.

METHODS

This retrospective single institution study included 502 consecutive patients who had undergone resection of ESCC. The Cox proportional hazard model was used to compute the hazard ratio (HR) for mortality.

RESULTS

Postoperative complications (≥Clavien-Dindo classification grade 2) occurred in 217 patients (43%). Overall, postoperative complications did not affect long-term clinical outcomes of these patients. However, patients with pulmonary complications had worse overall survival than those without pulmonary complications [log rank P = 0.0002; univariate HR = 1.51, 95% confidence interval (CI) 1.20-1.88, P = 0.0006; multivariate HR = 1.60, 95% CI 1.05-2.38, P = 0.029]. The effect of pulmonary complications was not significantly modified by clinical or pathological features (P for all assessed interactions >0.05). In addition, postoperative chylothorax was also associated with poor overall survival (log rank P = 0.0021), whereas surgical site infection, recurrent nerve paralysis, cardiovascular complication, and anastomotic leakage were not.

CONCLUSIONS

Postoperative pulmonary complications may be an independent predictor of poorer long-term survival in patients undergoing resection of ESCCs.

Risk Adjustment and Performance Measurement for Esophageal Cancer Resection

Achieving high-quality care for all patients undergoing esophageal cancer requires identifying and modifying risk factors associated with poor outcomes. These factors occur at different time points from the preoperative to the postoperative periods. A straightforward model for predicting outcomes has proved difficult to identify. This article reviews the current studies addressing risk adjustment and performance measurement for esophageal cancer resection.

Patterns of Care and Treatment Outcomes of Elderly Patients with Stage I Esophageal Cancer: Analysis of the National Cancer Data Base

INTRODUCTION

This study analyzes practice patterns, treatment-related mortality, survival, and predictors thereof in elderly patients with early-stage esophageal cancer (EC).

METHODS

The National Cancer Data Base was queried for cT1-2 N0 EC in patients 80 years of age and older. Patients were divided into four treatment groups: observation (Obs), chemoradiotherapy (CRT), local excision (LE), and esophagectomy (Eso). Patient, tumor, and treatment parameters were extracted and compared. Analyses were performed on overall survival (OS) and postoperative 30- and 90-day mortality.

RESULTS

A total of 923 patients from 2004 to 2012 were analyzed. Of these, 43% underwent clinical Obs, 22% underwent CRT, 25% underwent LE, and 10% underwent Eso. Patients undergoing Obs were older, had more comorbidities, were treated at nonacademic centers, and lived 25 miles or less from the facility. Patients receiving an operation (Eso or LE) were more often younger, male, white, and in the top income quartile. The postoperative 30-day mortality rates in the LE and Eso groups were 1.3% and 9.6%, respectively (p < 0.001) and increased to 2.6% and 20.2% at 90 days, respectively (p < 0.001). The 5-year OS rate was 7% for Obs, 20% for CRT, 33% for LE, and 45% for Eso (p < 0.001). Multivariate analyses showed improved OS with any local definitive therapy: CRT (hazard ratio [HR] = 0.42, 95% confidence interval [CI]: 0.34-0.52, p < 0.001), LE (HR = 0.3, 95% CI: 0.24-0.38, p < 0.001), and Eso (HR = 0.32, 95% CI: 0.23-0.44, p < 0.001).

CONCLUSIONS

There are noteworthy demographic, socioeconomic, and regional disparities influencing management of elderly patients with stage I EC. Despite high rates of Obs, careful consideration of all local therapy options is warranted, given the improved outcomes with treatment.

Introduction of Minimally Invasive Esophagectomy in a Community Teaching Hospital

Background and Objectives:

The safety of minimally invasive esophagectomy (MIE) outside of high-volume centers has not been studied. Therefore, we evaluated our experience with the introduction of MIE in the setting of a community teaching hospital.

Methods:

A retrospective cohort of all elective esophagectomy patients treated in a community hospital from 2008 through 2015 was evaluated (n = 57; open = 31 vs MIE = 26). Clavien-Dindo complication grades were recorded prospectively.

Results:

Mean age was 63 ± 11 years (range, 30–83), mean Charlson comorbidity index was 4.5 ± 1.7 and proportion of ASA score ≥3 was 87%. The groups did not differ in age, gender distribution, or comorbidity indices. There were 108 complications observed, including 2 deaths (3.5%, both coronary events). Postoperative complication rate was 77.1% and serious complication rate (grades 3 and 4) was 50.8% in the entire cohort. The rate of serious complications was similar (58% for open vs 42% for MIE group; 2-sided P = .089). MIE operations were longer (342 ± 109 vs 425 ± 74 minutes; P = .001). Length of stay trended toward not being significantly shorter among MIE cases (15 ± 13 vs 12 ± 12 days; P = .071). Logistic regression models including MIE status were not predictive of complications.

Conclusions:

Introduction of MIE esophagectomy in our community hospital was associated with prolonged operative time, but no detectable adverse outcomes. Length of stay was nonsignificantly shortened by the use of MIS esophagectomy.

A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

BACKGROUND

Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks.

METHODS

We performed a non-randomized retrospective observational study on the 75 (subcutaneous: 21, intrathoracic: 54) esophageal cancer patients who underwent esophageal reconstruction either through subcutaneous or intrathoracic route between January 2003 and February 2015. Preoperative data including the estimated reasons for the selection of the subcutaneous route were obtained from medical charts. Clinical outcomes were evaluated and compared between the two groups.

RESULTS

The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group.

CONCLUSIONS

Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Validation of microRNA pathway polymorphisms in esophageal adenocarcinoma survival

Polymorphisms in miRNA and miRNA pathway genes have been previously associated with cancer risk and outcome, but have not been studied in esophageal adenocarcinoma outcomes. Here, we evaluate candidate miRNA pathway polymorphisms in esophageal adenocarcinoma prognosis and attempt to validate them in an independent cohort of esophageal adenocarcinoma patients. Among 231 esophageal adenocarcinoma patients of all stages/treatment plans, 38 candidate genetic polymorphisms (17 biogenesis, 9 miRNA targets, 5 pri-miRNA, 7 pre-miRNA) were genotyped and analyzed. Cox proportional hazard models adjusted for sociodemographic and clinicopathological covariates helped assess the association of genetic polymorphisms with overall survival (OS) and progression-free survival (PFS). Significantly associated polymorphisms were then evaluated in an independent cohort of 137 esophageal adenocarcinoma patients. Among the 231 discovery cohort patients, 86% were male, median diagnosis age was 64 years, 34% were metastatic at diagnosis, and median OS and PFS were 20 and 12 months, respectively. GEMIN3 rs197412 (aHR = 1.37, 95%CI: [1.04-1.80]; P = 0.02), hsa-mir-124-1 rs531564 (aHR = 0.60, 95% CI: [0.53-0.90]; P = 0.05), and KIAA0423 rs1053667 (aHR = 0.51, 95% CI: [0.28-0.96]; P = 0.04) were found associated with OS. Furthermore, GEMIN3 rs197412 (aHR = 1.33, 95% CI: [1.03-1.74]; P = 0.03) and KRT81 rs3660 (aHR = 1.29, 95% CI: [1.01-1.64]; P = 0.04) were found associated with PFS. Although none of these polymorphisms were significant in the second cohort, hsa-mir-124-1 rs531564 and KIAA0423 rs1053667 had trends in the same direction; when both cohorts were combined together, GEMIN3 rs197412, hsa-mir-124-1 rs531564, and KIAA0423 rs1053667 remained significantly associated with OS. We demonstrate the association of multiple miRNA pathway polymorphisms with esophageal adenocarcinoma prognosis in a discovery cohort of patients, which did not validate in a separate cohort but had consistent associations in the pooled cohort. Larger studies are required to confirm/validate the prognostic value of these polymorphisms in esophageal adenocarcinoma.

Surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity

INTRODUCTION

The elucidation of the clinical impact of comorbidities is important to optimize the treatment and follow-up strategy in oesophageal cancer. We aimed to clarify the surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity.

METHODS

A total of 658 consecutive patients who underwent oesophagectomy for oesophageal cancer between 1985 and 2008 at our institution were enrolled. Based on the criteria of comorbidity as we defined it, we retrospectively reviewed and compared the surgical outcomes and survival between the comorbid (n = 251) and non-comorbid group (n = 407).

RESULTS

Postoperative morbidity and mortality were not significantly different between the two groups. The 5-year overall survival rate of the comorbid group was significantly lower (39.3% vs. 45.2%, adjusted HR = 1.31, 95% CI: 1.07-1.62) but the 5-year disease-specific survival rate was not significantly different between the comorbid and non-comorbid groups (53.9% vs. 53.1%, adjusted HR = 1.11, 95% CI: 0.86-1.42). The 5-year incidence rate of death from other diseases in the comorbid group was significantly higher than that in the non-comorbid group (26.7% vs. 14.8%, P < 0.01). The leading cause of death from other diseases was pneumonia.

CONCLUSIONS

Oesophagectomy in oesophageal cancer patients with comorbidity can be safely performed. However, the overall survival after oesophagectomy in these patients was unfavorable because of the high incidence of death from other diseases, especially pneumonia.

Impact of hospital volume on risk-adjusted mortality following oesophagectomy in Japan

Background

Previous studies have reported that patients undergoing oesophagectomy in high-volume hospitals experience lower mortality rates. However, there has been ongoing discussion regarding the validity of evidence for this association. The purpose of this study was to investigate the relationship between hospital volume and risk-adjusted mortality following oesophagectomy in Japan, using a nationwide web-based database.

Methods

The study included patients registered in the database as having undergone oesophagectomy with reconstruction between 2011 and 2013. Outcome measures were 30-day and operative mortality rates. Logistic regression analysis was used to adjust for hospital volume, surgeon volume and risk factors for mortality after oesophagectomy.

Results

A total of 16 556 oesophagectomies at 988 hospitals were included; the overall unadjusted 30-day and operative mortality rates were 1·1 and 3·0 per cent respectively. The unadjusted operative mortality rate in hospitals performing fewer than ten procedures per year (5·1 per cent) was more than three times higher than that in hospitals conducting 30 or more procedures annually (1·5 per cent). Multivariable models indicated that hospital volume had a significant effect on 30-day (odds ratio 0·88 per 10-patient increase; P = 0·012) and operative (odds ratio 0·86 per 10-patient increase; P &lt; 0·001) mortality.

Conclusion

In Japan, high-volume hospitals had lower risk-adjusted 30-day and operative mortality rates following oesophagectomy compared with low-volume hospitals.

The value of esophagectomy surgical apgar score (eSAS) in predicting the risk of major morbidity after open esophagectomy

BACKGROUND

Recently, surgical apgar score (SAS) has been reported to be strongly associated with major morbidity after major abdominal surgery. The aim of this study was to assess the value of esophagectomy SAS (eSAS) in predicting the risk of major morbidity after open esophagectomy in a high volume cancer center.

METHODS

The data of all patients who admitted to intensive care unit (ICU) after open esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences & Peking Union Medical College from September 2008 through August 2010 was retrospectively collected and reviewed. Preoperative and perioperative variables were recorded and compared. The eSAS was calculated as the sum of the points of EBL, lowest MAP and lowest HR for each patient. Patients were divided into high-risk (below the cutoff) and low-risk (above the cutoff) eSAS groups according to the cutoff score with optimal accuracy of eSAS for major morbidity. Univariable and multivariable regression analysis were used to define risk factors of the occurrence of major morbidity.

RESULTS

Of 189 patients, 110 patients developed major morbidities (58.2%) and 30-day operative mortality was 5.8% (11/189). There were 156 high risk patients (eSAS ≤7) and 33 low risk (eSAS >7) patients. Univariable analysis demonstrated that forced expiratory volume in one second of predicted (FEV1%) ≤78% (44% vs. 61%, P=0.024), McKeown approach (22.7% vs. 7.6%, P=0.011), duration of operation longer than 230 minutes, intraoperative estimated blood loss (347±263 vs. 500±510 mL, P=0.015) and eSAS ≤7 (62.2% vs. 90.0%, P=0.001) were predictive of major morbidity. Multivariable analysis demonstrated that FEV1% ≤78% (OR, 2.493; 95% CI, 1.279-4.858, P=0.007) and eSAS ≤7 (OR, 2.810; 95% CI, 1.105-7.144; P=0.030) were independent predictors of major morbidity after esophagectomy. Compared with patients who had eSAS >7, patients who had eSAS ≤7 had longer hospital length of stay (25.39±14.36 vs. 32.22±22.66 days, P=0.030). However, there were no significant differences in ICU length of stay, duration of mechanical ventilation, ICU death, 30-day death rate and in-hospital death rate between high risk and low risk patients.

CONCLUSIONS

The eSAS score is predictive of major morbidity, and lower eSAS is associated with longer hospital length of stay in esophageal cancer patients after open esophagectomy.

Operating on Patients Who Smoke: A Survey of Thoracic Surgeons in the United States

BACKGROUND

Although preoperative smoking is associated with increased postoperative complications in patients who undergo major thoracic surgical procedures, there are no national guidelines that address the patient's preoperative tobacco use. This study examined the typical preoperative management of thoracic surgical patients who are smokers.

METHODS

The link to an anonymous survey was emailed to cardiothoracic surgeons in the United States. The survey included questions regarding the likelihood of a surgeon to offer surgery and strategies used to assist patients in quitting smoking before surgery.

RESULTS

The majority of the 158 surgeons who responded to the survey were general thoracic surgeons (68%, 107 of 158), in an academic practice (57%, 90 of 158), with more than 15 years of experience (51%, 81 of 158). An overwhelming majority of respondents (98.1%, 155 of 158) considered smoking preoperatively a risk factor for postoperative complications. The most common cessation strategy offered to smokers was pharmacologic intervention (77%, 122 of 158). Nearly half of the surgeons (47%, 74 of 156) would not perform certain operations in a patient who was a current smoker, but only 14% (10 of 74) tested patients preoperatively for smoking. Thoracic surgeons (odds ratio 2.1, p = 0.0379) and surgeons in academic practice (odds ratio 1.9, p = 0.057) were more likely to deny certain surgeries to current smokers. Two thirds of the surgeons (66%, 48 of 74) thought that the ideal wait time from smoking cessation to surgery was 2 to 4 weeks.

CONCLUSIONS

There is significant disagreement in the cardiothoracic surgical community regarding how to treat patients who smoke, especially when deciding to deny or postpone surgery. Prospective studies and guidelines are needed.

Comparative Effectiveness of Esophagectomy Versus Endoscopic Treatment for Esophageal High-grade Dysplasia

OBJECTIVE

The purpose of this study is to determine the comparative effectiveness of esophagectomy versus endoscopic mucosal resection followed by radiofrequency ablation (EMR-RFA) for the treatment of Barrett esophagus with high-grade dysplasia (HGD).

BACKGROUND

HGD of the esophagus may be managed by surgical resection or EMR-RFA. National guidelines suggest that EMR-RFA is effective at eradicating HGD. The comparative effectiveness and cost-effectiveness of EMR-RFA versus esophagectomy for HGD remains unclear.

METHODS

A decision-analysis model was constructed to represent 3 management strategies for HGD: (1) esophagectomy, (2) EMR-RFA, and (3) endoscopic surveillance. Estimates for model variables were obtained from literature review, and costs were estimated from Medicare fee schedules. Costs and utilities were discounted at an annual rate of 3%. The baseline model was adjusted for alternative age groups and high-risk dysplastic variants. One-way and multivariable probabilistic sensitivity analyses were conducted.

RESULTS

For a 65-year-old patient, compared to esophagectomy, EMR-RFA yields equivalent utility (11.5 vs 11.4 discounted quality-adjusted life years) with lower total cost ($52.5K vs $74.3K) over the first 20 years. Dominance of EMR-RFA over esophagectomy persists for all age groups. Patients with diffuse or ulcerated HGD are more effectively treated with esophagectomy. Model outcomes are sensitive to estimated rates of disease progression and postintervention utility parameters.

CONCLUSIONS

Existing evidence supports EMR-RFA over esophagectomy for the treatment of esophageal HGD. Long-term outcomes and more definitive quality-of-life studies for both interventions are crucial to better inform decision-making.

Recent improvements in the management of esophageal anastomotic leak after surgery for cancer

Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.

Predictors of Major Morbidity or Mortality After Resection for Esophageal Cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database Risk Adjustment Model

BACKGROUND

The purpose of this analysis was to revise the model for perioperative risk for esophagectomy for cancer utilizing The Society of Thoracic Surgeons General Thoracic Surgery Database to provide enhanced risk stratification and quality improvement measures for contributing centers.

METHODS

The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for all patients treated for esophageal cancer with esophagectomy between July 1, 2011, and June 30, 2014. Multivariable risk models for major morbidity, perioperative mortality, and combined morbidity and mortality were created with the inclusion of surgical approach as a risk factor.

RESULTS

In all, 4,321 esophagectomies were performed by 164 participating centers. The most common procedures included Ivor Lewis (32.5%), transhiatal (21.7%), minimally invasive esophagectomy, Ivor Lewis type (21.4%), and McKeown (10.0%). Sixty-nine percent of patients received induction therapy. Perioperative mortality (inpatient and 30-day) was 135 of 4,321 (3.4%). Major morbidity occurred in 1,429 patients (33.1%). Major morbidities include unexpected return to operating (15.6%), anastomotic leak (12.9%), reintubation (12.2%), initial ventilation beyond 48 hours (3.5%), pneumonia (12.2%), renal failure (2.0%), and recurrent laryngeal nerve paresis (2.0%). Statistically significant predictors of combined major morbidity or mortality included age more than 65 years, body mass index 35 kg/m(2) or greater, preoperative congestive heart failure, Zubrod score greater than 1, McKeown esophagectomy, current or former smoker, and squamous cell histology.

CONCLUSION

Thoracic surgeons participating in The Society of Thoracic Surgeons General Thoracic Surgery Database perform esophagectomy with low morbidity and mortality. McKeown esophagectomy is an independent predictor of combined postoperative morbidity or mortality. Revised predictors for perioperative outcome were identified to facilitate quality improvement processes and hospital comparisons.

The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes

BACKGROUND

The Society of Thoracic Surgeons (STS) creates risk-adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort.

METHODS

We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012, through December 31, 2014. Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity, and composite mortality and major morbidity.

RESULTS

In all, 27,844 lung cancer resections were performed at 231 centers; 62% (n = 17,153) were performed by thoracoscopy. The mortality rate was 1.4% (n = 401), major morbidity rate was 9.1% (n = 2,545), and the composite rate was 9.5% (n = 2,654). Predictors of mortality included age, being male, forced expiratory volume in 1 second, body mass index, cerebrovascular disease, steroids, coronary artery disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection (all p < 0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor whereas stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance.

CONCLUSIONS

Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined, and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data are audited for quality assurance.

Assessment of a predictive score for pulmonary complications in cancer patients after esophagectomy

BACKGROUND

Esophagectomy is a very important method for the treatment of resectable esophageal cancer, which carries a high rate of morbidity and mortality. This study was undertaken to assess the predictive score proposed by Ferguson et al for pulmonary complications after esophagectomy for patients with cancer.

METHODS

The data of patients who admitted to the intensive care unit after transthoracic esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between September 2008 and October 2010 were retrospectively reviewed.

RESULTS

Two hundred and seventeen patients were analyzed and 129 (59.4%) of them had postoperative pulmonary complications. Risk scores varied from 0 to 12 in all patients. The risk scores of patients with postoperative pulmonary complications were higher than those of patients without postoperative pulmonary complications (7.27±2.50 vs. 6.82±2.67; P=0.203). There was no significant difference in the incidence of postoperative pulmonary complications as well as in the increase of risk scores (χ (2)=5.477, P=0.242). The area under the curve of predictive score was 0.539±0.040 (95%CI 0.461 to 0.618; P=0.324) in predicting the risk of pulmonary complications in patients after esophagectomy.

CONCLUSION

In this study, the predictive power of the risk score proposed by Ferguson et al was poor in discriminating whether there were postoperative pulmonary complications after esophagectomy for cancer patients.

Comorbidities and Risk of Complications After Surgery for Esophageal Cancer: A Nationwide Cohort Study in Sweden

BACKGROUND

The selection for surgery is multifaceted for patients diagnosed with esophageal cancer. Since it is uncertain how comorbidity should influence the selection, this study addressed comorbidities in relation to risk of severe complications following esophageal cancer surgery.

METHODS

This population-based cohort study was based on prospectively included patients who underwent surgical resection for an esophageal or gastro-esophageal junctional cancer in Sweden during 2001-2005. The participation rate was 90%. Associations between pre-defined comorbidities and pre-defined post-operative complications occurring within 30 days of surgery were analyzed using multivariable logistic regression. The resulting odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for age, sex, tumor stage, tumor histology, neoadjuvant therapy, type of surgery, annual hospital volume, other comorbidities, and other complications.

RESULTS

Among 609 included patients, those with cardiac disease (n = 92) experienced an increased risk of pre-defined complications in general (adjusted OR 1.81, 95% CI 1.13-2.90), while patients with hypertension (n = 137), pulmonary disorders (n = 79), diabetes (n = 67), and obesity (n = 66) did not. Patients with a Charlson comorbidity index score ≥2 had substantially increased risks of pre-defined complications (adjusted OR 2.44, 95% CI 1.60-3.72).

CONCLUSION

Cardiac disease and a Charlson comorbidity index score ≥2 seem to increase the risk of severe and early post-operative complications in patients with esophageal cancer, while hypertension, pulmonary disorders, diabetes, and obesity do not. These findings should be considered in the clinical decision-making for improved selection of patients for surgery.

Minimally invasive esophagectomy in a patient with end-stage renal disease

Renal failure has been identified as a major predictor of surgical complications and esophagectomy carries high morbidity for patients. We discuss the preoperative and postoperative considerations for performing a minimally invasive Ivor-Lewis esophagectomy for a benign long-segment stricture in a patient with end-stage renal failure.

Sarcopenia as a predictor of pulmonary complications after esophagectomy for thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

Sarcopenia or loss of skeletal muscle mass has been identified as a poor prognostic factor for a wide variety of diseases and conditions. We investigated whether preoperative sarcopenia is associated with postoperative complications in patients undergoing esophagectomy for thoracic esophageal cancer.

METHODS

We retrospectively reviewed the medical records of consecutive patients with thoracic esophageal cancer who underwent esophagectomy between September 2005 and July 2014 at Kyoto University Hospital. Skeletal muscle mass was assessed using preoperative computed tomographic scans by measuring the cross-sectional muscle area at the third lumbar vertebral level.

RESULTS

Among the 199 eligible patients, 149 (75%) were classified as having sarcopenia. There was no difference in the incidence of overall complications between the groups (risk ratio [RR]: 1.10, 95% confidence interval [CI]: 0.80-1.53, P = 0.54). However, pulmonary complications were significantly more frequent in the sarcopenia group than in the nonsarcopenia group (RR: 2.63, 95% CI: 1.20-5.77, P = 0.007). Multivariate analyses demonstrated that sarcopenia was associated with a high adjusted risk of one or more pulmonary complications (odds ratio: 2.96, 95% CI: 1.14-7.69, P = 0.026).

CONCLUSIONS

Sarcopenia independently predicts pulmonary complications after esophagectomy for thoracic esophageal cancer. J. Surg. Oncol. 2016;113:678-684. © 2016 Wiley Periodicals, Inc.