Risk analysis in resection of squamous cell carcinoma of the esophagus

Essential risk factors for operative mortality in elderly esophageal cancer patients registered in the National Clinical Database of Japan

BACKGROUND

With the aging of society and increasingly longer of life expectancy, elderly patients with esophageal cancer are more commonly encountered. This study aimed to identify the risk factors for operative mortality after esophagectomy in elderly patients.

METHODS

We used data from the National Clinical Database of Japan. After cleaning the data, 10,633 records obtained from 861 hospitals were analyzed. A risk model for operative mortality was developed using risk factors from the entire study population. Then, odds ratios (OR) were compared between age categories using this risk model.

RESULTS

In this study, 1959 (18.4%) patients were ≥ 75 years (defined as "elderly" in this study). Eighteen variables, including T4b, N2-N3, and M1 in the TNM classification, were included in the risk model for operative mortality. The ORs increased in age categories < 65, 65-74, and ≥ 75 years for N2-N3 (1.172, 1.200, and 1.588, respectively), and M1 (2.189, 3.164, and 4.430, respectively). Based on these results, we also focused on residual tumors, which are caused by extensive tumor development. The operative mortality in the elderly group with residual tumors increased to more than twice than that in the non-elderly groups (15.9 vs. 5.5 or 6.5%) and was much higher than that in elderly patients without residual tumors (15.9 vs. 4.6%).

CONCLUSION

We should carefully select the treatment for elderly patients with highly advanced tumors, which result in N2-N3 and M1, to avoid unfavorable short-term outcomes. In addition, R0 resection is important in preventing operative mortality among elderly patients.

Intraoperative hypotension is not associated with adverse short-term postoperative outcomes after esophagectomy in esophageal cancer patients

Background

The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied.

Methods

A prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastric anastomosis for esophageal cancer. Intraoperative hypotension (IOH), defined as systolic blood pressure (SBP) < 90 mm Hg lasting more than 5 min, was recorded. Patients’ 30 days post-operative composite outcome of mortality, anastomotic leak, and prolonged hospital stay were analyzed as outcome variables.

Result

A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. The mean duration of the surgery was 208 min. Intraoperative mean low SBP was 80 mmHg while the lowest record was 55 mmHg. IOH occurred in 51% (n = 29) of patients. Anastomotic leak occurred in 7% (n = 4) (OR 1.2, 95% CI 0.26–6.3; p = 0.76). In-hospital mortality was 5% (n = 3) (OR 1.44, 95% CI 0.22–9.3; p = 0.7) and 33% (n = 18) had prolonged hospital stay (OR 0.53, 95% CI 0.14–1.9; p = 0.34). The overall anastomotic leak rate was 13% (n = 7). Multivariate analysis (logistic regression model) showed SBP < 90 mmHg for more than 5 min was not significantly associated either with individual or composite outcomes of mortality, anastomotic leak, and prolonged hospital stay (AOR 1.06, 95% CI 0.98–1.14; p = 0.16)

Conclusion

In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association with composite adverse outcomes of mortality, anastomotic leak, and prolonged hospital stay.

Determination of the optimal surgical procedure by identifying risk factors for pneumonia after transthoracic esophagectomy

BACKGROUND

Esophagectomy is associated with a high risk of postoperative complications, and the respiratory complications are the most common. Therefore, stratification of patients based on preoperative risk factors is essential. This study aimed to identify the risk of postoperative pneumonia (POP) based on the preoperative factors and determine the optimal perioperative surgical management strategy.

METHODS

This retrospective study involved 207 patients who underwent esophagectomy. The patients were divided into two groups, namely, with POP and without POP. To identify the risk factors for POP, the pre- and perioperative characteristics were analyzed. A receiver operating characteristics curve was used to determine a cutoff value of 2.40 L for the forced expiratory volume in 1 s (FEV1.0) and the cohort was divided into a high- and low-FEV1.0 group. A second analysis was then performed to determine the optimal surgical management for patients at a high risk for POP.

RESULTS

POP occurred in 45 (21.7%) patients. A multiple logistic regression analysis showed that FEV1.0 was significantly lower in the POP (+) group (P = 0.020); thus, a low FEV1.0 was found to be a risk factor for POP. Multiple logistic regression analysis showed that open thoracotomy was a significant risk factor for POP in low FEV1.0 patients (P = 0.013).

CONCLUSIONS

A low FEV1.0 and an open thoracotomy are risk factors for POP. Therefore, patients with low FEV1.0 should be managed carefully and video-assisted thoracic surgery should be considered.

Long-term outcomes after hand-sewn versus circular-stapled (25 and 29 mm) anastomotic technique after esophagogastrectomy for esophageal cancer

BACKGROUND

Anastomotic stricture following esophagogastrectomy (EG) can lead to significant dysphagia, necessitating interventions such as endoscopic dilatation. These post-operative complications gain importance with the increased survival rate of patients after EG. This study aimed to assess the outcomes of both circular-stapled (CS: 25 and 29 mm) and hand-sewn (HS) anastomoses after EG.

METHODS

We reviewed prospectively accrued data from December 2004 to December 2014 identifying all patients undergoing EG for esophageal cancer. Immediate post-operative and long-term complications were noted. Primary outcome measures included anastomotic leak and stricture, dysphagia, and subsequent.

RESULTS

A total of 142 patients were identified for analysis. The method used for reconstruction was noted: CS-EEA-25 mm (n = 30), CS-EEA-29 mm (n = 30), and HS (n = 82). Demographics, tumor pathology, and tumor locations were similar in each group. All groups experienced similar rates of anastomotic leak, stricture, and dysphagia. Furthermore, post-operative dilations for symptomatic dysphagia were required in 3 (10%), 4 (13%), and 9 (11%) patients, P = 0.91.

CONCLUSION

In this cohort, the method of anastomotic construction had no bearing on the rate of complications after EG for the treatment of esophageal cancer. Furthermore, long-term need for dilations for symptomatic dysphagia was equal among all groups.

Association between Postoperatively Developed Atrial Fibrillation and Long-Term Mortality after Esophagectomy in Esophageal Cancer Patients: An Observational Study

Background

Newly developed atrial fibrillation (AF) in patients who have undergone an esophagectomy increases the incidence of postoperative complications. However, the clinical implications of AF have not been fully elucidated in these patients. This retrospective observational study investigated the predictors for AF and the effect of AF on the mortality in esophageal cancer patients undergoing esophagectomy.

Methods

This study evaluated 583 patients undergoing esophagectomy, from January 2005 to April 2012. AF was defined as newly developed postoperative AF requiring treatment. The risk factors for AF and the association between AF and mortality were evaluated. The long-term mortality was the all-cause mortality, for which the cutoff date was May 31, 2014.

Results

AF developed in 63 patients (10.8%). Advanced age (odds ratio [OR] 1.099, 95% confidence interval [CI] 1.056–1.144, P < 0.001), preoperative calcium channel blocker (CCB) (OR 2.339, 95% CI 1.143–4.786, P = 0.020), and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (OR 0.206, 95% CI 0.067–0.635, P = 0.006) were associated with the incidence of AF. The Kaplan-Meier curve showed a significantly lower survival rate in the AF group compared to the non-AF group (P = 0.045), during a median follow-up of 50.7 months. The multivariable analysis revealed associations between AF and the 1-year mortality (hazard ratio [HR] 2.556, 95% CI 1.430–4.570, P = 0.002) and between AF and the long-term mortality (HR 1.507, 95% CI 1.003–2.266, P = 0.049).

Conclusions

In esophageal cancer patients, the advanced age and the preoperative medications (CCB, ACEI or ARB) were associated with the incidence of AF. Furthermore, postoperatively developed AF was associated with mortality in esophageal cancer patients after esophagectomy, suggesting that a close surveillance might be required in patients who showed AF during postoperative period.

Preoperative chemotherapy in patients with resectable esophageal carcinoma: a single center Phase II study

OBJECTIVE

The role of preoperative chemotherapy in squamous cell esophageal carcinoma remains controversial. A prospective trial was initiated to investigate whether preoperative chemotherapy followed by surgery results in increased progression-free survival in patients with resectable thoracic esophageal carcinoma.

METHODS

Patients with Stage IIb-IIIa/b resectable esophageal carcinoma were eligible for the study. They received two cycles of FLEP regimen chemotherapy (cisplatin, etoposide, leucovorine, 5-fluorouracil) followed by transthoracic extended 2- or 3-field esophagectomy. Two-year progression-free survival was the primary endpoint. To evaluate the potential benefit of the dual-modality approach we compared these results with the outcome of patients who were treated in our center in the same period of time and were non-randomly allocated to surgery alone.

RESULTS

From 2001 to 2008, 63 patients were included in the study (bimodality group) and 58 patients into the surgery-alone group. Median follow-up was 68 (range, 4-123) months. Squamous cell carcinoma had 93% patients. Two-year progression-free survival for all patients was 45.3 and 30.7% (hazard ratio 0.71, 95% confidence interval 0.46-1.08) and median overall survival was 26.5 months and 18.0 months (hazard ratio 0.67, 95% confidence interval 0.41-1.01) in bimodality- and surgery-alone groups, respectively. Patients who underwent R0-resection after bimodality treatment had significantly better overall survival (40.9 months) than after surgery alone (19.0 months, hazard ratio 0.51, 95% confidence interval 0.30-0.81).

CONCLUSIONS

Two cycles of preoperative chemotherapy did not improve progression-free survival of patients with resectable thoracic esophageal carcinoma in intent-to-treat population. However, significantly better results of bimodality approach was seen in R0-resected patients which warrants further trials with more effective chemotherapy combinations.

Predictive Effects of Lung function test on Postoperative Pneumonia in Squamous Esophageal Cancer

Pulmonary function tests had prospective implications for postoperative pneumonia, which occurred frequently after esophagectomy. Understanding factors that were associated with pulmonary infection may help in patient selection and postoperative management. We performed a retrospective review of 2 independent cohorts including 216 patients who underwent esophagectomy between November 2011 and May 2014, aiming at identifying predictors of primary pneumonia. Univariate analysis was used to identify potential covariates for the development of primary pneumonia. Adjustments for multiple comparisons were made using False Discovery Rate (FDR) (Holm-Bonferroni method). Multivariable logistic regression analysis was used to identify independent predictors and construct a regression model based on a training cohort (n = 166) and then the regression model was validated using an independent cohort (n = 50). It showed that low PEF (hazard ratio 0.97, P = 0.009) was independent risk factors for the development of primary pneumonia in multivariate analyses and had a predictive effect for primary pneumonia (AUC = 0.691 and 0.851 for training and validation data set, respectively). Therefore, PEF has clinical value in predicting postoperative pneumonia after esophagectomy and it may serve as an indicator of preoperative lung function training.

Preoperative chemoradiation therapy for esophageal cancer is a risk factor for the elevation of high mobility group box-1, leading to an increase in postoperative severe pulmonary complications

We herein clarified the time course of changes in the serum high mobility group box chromosomal protein-1 (HMGB-1) concentrations in esophageal cancer patients after esophagectomy, and investigated whether the perioperative serum HMGB-1 levels correlate with the administration of neoadjuvant chemoradiation therapy (NACRT) and the postoperative clinical course, especially the occurrence of pulmonary complications, in such patients. Sixty patients who underwent right transthoracic esophagectomy for esophageal cancer were enrolled in this study. The relationship between the perioperative serum HMGB-1 levels and NACRT, and the postoperative severe pulmonary complications were evaluated. Patients with severe pulmonary complications (n = 44) tended to have undergone NACRT more often than those without severe pulmonary complications (n = 16). The preoperative and postoperative day 7 serum HMGB-1 concentrations were significantly higher in patients with severe pulmonary complications than those in patients without severe pulmonary complications. In the univariate and multivariate analyses, the use of NACRT and the preoperative elevations in the serum HMGB-1 levels (>4.2 ng/mL) were found to be significantly associated with pulmonary dysfunction. Furthermore, the response to NACRT was found to be significantly associated with the preoperative serum HMGB-1 levels. The use of NACRT contributes to preoperative serum HMGB-1 elevation, and these were risk factors for the occurrence of severe postoperative pulmonary complications in patients with esophageal cancer after thoracic esophagectomy.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer

BACKGROUND

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections.

METHODS

The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure.

RESULTS

Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration.

CONCLUSION

Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems.

Management of complications of radical esophagectomy

The aim of this article is to describe management of complications of radical esophagectomy and to present outcome analysis of prospective study done on patients who underwent radical esophagectomy with 3FLND in our institution. The data analysis and results of our study and its comparison with current literature suggests that improvement in anaesthesia delivery, proper patient selection, refinements in surgical techniques and improved perioperative care are associated with decreased complication rates, morbidity and mortality thereby improving outcome in terms of overall survival with decreased rate of loco regional recurrence.

Prevention of postoperative pulmonary complications through intensive preoperative respiratory rehabilitation in patients with esophageal cancer

Postoperative pulmonary complications (PPCs) after esophagectomy have been reported to occur in 15.9-30% of patients and lead to increased postoperative morbidity and mortality, prolonged duration of hospital stay, and additional medical costs. The purpose of this retrospective cohort study was to investigate the possible prevention of PPCs by intensive preoperative respiratory rehabilitation in esophageal cancer patients who underwent esophagectomy. The subjects included 100 patients (87 males and 13 females with mean age 66.5 ± 8.6 years) who underwent esophagectomy. They were divided into two groups: 63 patients (53 males and 10 females with mean age 67.4 ± 9.0 years) in the preoperative rehabilitation (PR) group and 37 patients (34 males and 3 females with mean age 65.0 ± 7.8 years) in the non-PR (NPR) group. The PR group received sufficient preoperative respiratory rehabilitation for >7 days, and the NPR group insufficiently received preoperative respiratory rehabilitation or none at all. The results of the logistic regression analysis and multivariate analysis to correct for all considerable confounding factors revealed the rates of PPCs of 6.4% and 24.3% in the PR group and NPR group, respectively. The PR group demonstrated a significantly less incidence rate of PPCs than the NPR group (odds ratio: 0.14, 95% confidential interval: 0.02~0.64). [Correction added after online publication 25 June 2012: confidence interval has been changed from -1.86~ -0.22] This study showed that the intensive preoperative respiratory rehabilitation reduced PPCs in esophageal cancer patients who underwent esophagectomy.

Impact of the surgical technique on pulmonary morbidity after esophagectomy

BACKGROUND

Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors.

METHODS

We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality.

RESULTS

A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality.

CONCLUSIONS

Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

Pulmonary Complications due to Esophagectomy

INTRODUCTION

Esophageal carcinoma is the scourge of human beings. Pulmonary complications in patients who have undergone operation are common (20-30% of cases) and there are no suitable tools and ways to predict these complications.

METHODS

During a period of 10 years, from March 1998 to February 2007, 200 patients (150 male and 50 female) underwent Esophagectomy due to esophageal carcinoma in thoracic surgery ward retrospectively. Complications include the length of hospitalization, mechanical ventilation, morbidity and mortality. Patients' risk factors include age, preoperative chemo-radiotherapy, stage of the disease and preoperative spirometry condition.

RESULTS

WE GROUPED OUR PATIENTS INTO THREE CATEGORIES: Normal (FEV1 ≥ 80% predicted), mildly impaired (FEV1 65% to 79% predicted), more severely impaired (FEV1 < 65% predicted).Although almost all patients had radiographic pulmonary abnormalities, significant pulmonary complications occurred in 40 patients (20%) which underwent Esophagectomy. Pleural effusion and atelectasia in 160 patients (80%). 24 patients needed chest-tube insertion. 20 patients (10%) developed ARDS. 14 patients (7%) developed chylothorax. 20 patients (10%) of patients died during their postoperative hospital stay. 30 patients (15%) required mechanical ventilation for greater than 48 hours.

CONCLUSION

We reviewed a number of preoperative clinical variables to determine whether they contributed to postoperative pulmonary complications as well as other outcomes. In general, age, impaired pulmonary function especially in those patients with FEV1 less than 65% predicted was associated with prolonged hospital length of stay (LOS). In fact pulmonary complications rate after Esophagectomy are high and there was associated mortality and morbidity.

Perioperative fluid management and major respiratory complications in patients undergoing esophagectomy

Esophageal surgery is often related to a high morbidity and mortality rate despite an improvement in postoperative care. Fluid administration has been described to be a factor that contributes to the development of postoperative respiratory complications after esophageal surgery. The aim was to study the relation between intraoperative and postoperative fluid administration and the development of respiratory complications after esophageal surgery. Patients undergoing esophageal surgery for cancer were selected from a prospective nonrandomized computer database. All of the patients underwent esophagectomy according to the Lewis-Tanner approach. Single-lung ventilation was used in all of the patients during the thoracic approach. The patients were divided in two groups with respect to the development of respiratory complications. Variables studied were American Society of Anesthesiologist Score, sex, preoperative chemoradiotherapy, albumin, smoking history, time until extubation, epidural analgesia, and fluid administration intraoperatively and 5 days postoperatively. Forty-five patients were included in the study. Respiratory complications were observed in nine patients (20%). None of the variables studied except fluid administration (P= 0.005 - odds ratio = 1.001 -95% confidence interval) were shown as a risk factor for the development of respiratory complications on the multivariate analysis. Fluid administration intraoperatively and postoperatively has shown to be a contributing factor for the development of respiratory complications after esophageal surgery.

Esophagectomy without mortality: what can surgeons do?

INTRODUCTION

Surgical resection remains the mainstay treatment for patients with localized esophageal cancer. It is, however, a complex procedure. Mortality rate used to be high, but in recent years, death rate has been reduced to below 5% in specialized centers.

METHODS

Outcome of esophagectomy can be improved by paying attention to (1) appropriate patient section, (2) choice of surgical techniques and their execution, and (3) optimizing perioperative care. A volume-outcome relationship is also evident. Surgeons can perform esophagectomy without mortality, but a multi-disciplinary team management is essential to achieve this goal.

Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience

BACKGROUND

In patients with esophageal cancer and a history of gastric surgery, colonic interposition is the treatment of choice. Our aim was to review our experience with this technique and to identify possible predictors of the clinical outcome.

METHODS

Between 1986 and 2006, 43 patients underwent esophageal reconstruction accomplished by colon interposition in our surgical department. Data from these patients were collected consecutively and reviewed retrospectively.

RESULTS

Colon interposition was performed isoperistaltically in 15 patients and was performed in 28 patients anisoperistaltically. In 18 patients, the right colon was used for interposition, whereas in 25 patients, the left colon was used. The mean survival time was 23+/-29 months. Artificial ventilation more than 24h, tumor differentiation grade III, the presence of major complications, and the presence of multivisceral resection had a significant negative influence on the operative outcome of colon interposition for esophageal replacement.

CONCLUSION

Colon interposition for esophageal replacement provides a satisfactory operative outcome with high complication rates. Therefore, it should be reserved as a treatment of second choice for cases in which the stomach is not available.

Management of oesophageal cancer

Oesophageal cancer is a disease of dismal prognosis. There are variations of epidemiology among different ethnic groups and geographic regions. India is a country with high incidence. This can be attributed to the interplay between environmental, dietary factors and life-style of the population of the country. Optimal therapeutic strategy for patients with oesophageal cancer demands individual consideration.Majority of oesophageal cancer patients present at an advanced stage of disease. Screening programmes or strategies aiming at early diagnosis can improve the prognosis; unfortunately this is not cost-effective except in very high incidence areas. Accurate staging can help select the most appropriate treatments, such as excluding those patients with metastatic disease who are unlikely to benefit from surgery, and treating very early lesions with endoscopic means. When surgery is indicated, treating patient in a high-volume centre can improve the outcome and minimise complications. Although surgical resection remains the main treatment modality, long-term prognosis after surgical resection alone has been suboptimal except in those with early disease. Multidisciplinary approaches including chemotherapy and radiotherapy with or without surgery are increasingly employed for patients with advanced disease. Collaboration among surgeons, clinical oncologists, radiologists and physicians is of utmost importance to achieve the best results. Treatment for patients should be individualised to enhance outcome.

Surgical factors influence the outcome after Ivor-Lewis esophagectomy with intrathoracic anastomosis for adenocarcinoma of the esophagogastric junction: a consecutive series of 240 patients at an experienced center

BACKGROUND

Despite a considerable number of randomized studies, the surgical approach to locally advanced adenocarcinoma of the esophagogastric junction (AEG) I and II is still discussed controversially. Thus, we evaluated the surgical risk and outcome after an abdominothoracic esophagectomy (Ivor-Lewis) with intrathoracic anastomosis as standard procedure.

METHODS

Between 1998 and 2006, a total of 240 consecutive patients underwent standardized right thoracoabdominal esophagectomy with two-field lymphadenectomy and intrathoracic anastomosis (Ivor-Lewis operation) for AEG I (n = 206) or AEG II (n = 34). A total of 157 patients (65.4%) had neoadjuvant chemotherapy.

RESULTS

Postoperative morbidity occurred in 17.9% (43 of 240). Overall mortality was 3.8% (9 of 240). The majority of patients (4 of 9) died because of severe pulmonary complications (44.4%) irrespective of surgical complications. Neoadjuvant chemotherapy did not increase morbidity or mortality. The median overall survival was 51 months. Multivariate analysis including age >75 years, clinical response to chemotherapy, complications, R-category and N-category revealed R-category (P = .005; relative risk [RR] 0.32, 95% confidence interval [95% CI] 0.14-0.70) and complications (P < .001, RR 0.16, 95% CI 0.08-0.35) as independent prognostic factors for all patients. Complications was the only independent prognostic factor (P < .001, RR 0.09, 95% CI 0.08-0.35) for the R0 resected patients.

CONCLUSIONS

At an experienced center, Ivor-Lewis resection is a safe surgical procedure. Outcome of patients was significantly influenced by surgical factors such as complete resection and complications. Neoadjuvant chemotherapy did not lead to higher morbidity and mortality. The high mortality from non-surgery-related complications emphasizes the importance of careful preoperative evaluation of comorbidities and patient selection.

Is minimally invasive esophagectomy indicated for cancer?

Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40-60%) morbidity and 5-20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.

Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model

BACKGROUND

Surgical resection for the treatment of esophageal cancer remains a high-risk procedure. To develop a model to predict risk of postoperative death, we sought to identify factors associated with postoperative mortality for Medicare patients undergoing esophagectomy for cancer.

METHODS

We evaluated patients in the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare database who underwent esophagectomy for esophageal cancer from 1997 to 2003. Variables evaluated were patient age, race, marital status, sex, tumor stage, Charlson score, and hospital volume. Hospital volume was evaluated in tertiles of even volume groups (low, < .67 cases a year; medium, .68 to 2.33 cases a year; high, > 2.33 cases a year). The primary outcome measure was postoperative mortality, defined as death within 30 days of esophagectomy or death during the hospitalization in which the primary surgical procedure was performed. In-hospital deaths more than 30 days after esophagectomy were included in the outcomes to more accurately estimate the true mortality of this procedure. Multivariable logistic regression analyses were performed to evaluate the relationship between patient and provider characteristics and postoperative mortality. Finally, characteristics identified by the regression analysis were used to generate a simplified, clinically applicable model predicting risk of postoperative mortality in the Medicare population.

RESULTS

A total of 1172 patients underwent esophageal cancer surgery during this study period. Overall postoperative mortality was 14%. Multivariable logistic regression demonstrated that age, Charlson score, and hospital volume were statistically significant predictors of postoperative mortality. The other variables such as race, martial status, sex, and disease stage were not found to be significant. The odds of postoperative mortality at low-volume hospitals were almost twice those at a high-volume hospital. Age greater than 80 increased odds of mortality almost twofold. Similarly, Charlson scores of > or = 2 resulted in more than a 1.5-fold risk of postoperative mortality. Our prediction model using these variables accurately stratified postoperative mortality for this population.

CONCLUSIONS

Postoperative mortality (30-day and in-hospital) remains high after esophagectomy. Age, Charlson score, and hospital volume were identified as independent predictors of postoperative mortality. A simple risk prediction model that uses preoperative clinical data accurately predicted patient postoperative mortality for this SEER-Medicare population.

Predictive ability of preoperative indices for esophagectomy

Esophageal resection remains the mainstay of treatment for early-stage cancer. In spite of recent advances, these mortality rates remain significant when compared with other major surgical procedures. Several risk scores have been reported, but few have been put to the test with adequate and objective validation studies in high volume centers. Others already in use have poor discriminatory power.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Anaesthesia for oesophagectomy

PURPOSE OF REVIEW

To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy.

RECENT FINDINGS

Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery.

SUMMARY

Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.

Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery

BACKGROUND

Surgical outcomes after thoracoscopic esophagectomy were compared with those after open esophagectomy, and the prognostic values of factors potentially related to mortality and morbidity were evaluated.

METHODS

We performed a retrospective chart review of 153 patients who underwent esophagectomy for thoracic esophageal cancer. The thoracic surgical procedures were categorized into the following three groups: esophagectomy under standard thoracotomy (n = 37), assisted thoracoscopic esophagectomy with utility minithoracotomy (n = 38), and complete thoracoscopic esophagectomy (n = 78). Mortality and morbidity were compared among the three groups. Then, in a separate multivariate analysis, data on 14 potentially prognostic variables were extracted, and the relation to postoperative outcomes was examined.

RESULTS

Respiratory complications were the most frequent complications in all three groups, and their rate of occurrence was not significantly among the three groups. The 30-day and in-hospital mortality rates were significantly higher in the open group than in the other groups. Multivariate analysis demonstrated that patient age, sex, induction chemoradiation, and forced expiratory volume were independently significant contributing factors for respiratory complications, while the serum total protein concentration and open esophagectomy were significant factors for in-hospital mortality.

CONCLUSIONS

Our results demonstrated that respiratory complications are still the main cause of operative morbidity when using the thoracoscopic esophagectomy protocol and that use of the thoracoscopic procedure does not decrease the risk of respiratory complications. The use of the thoracoscopic procedure improved postoperative in-hospital mortality. The advantages of thoracoscopic esophagectomy should be investigated further. At this point in time, however, thoracoscopic esophagectomy can be considered a feasible, safe, and advantageous surgical option.

Preoperative risk analysis--a reliable predictor of postoperative outcome after transthoracic esophagectomy?

BACKGROUND AND AIMS

In patients with esophageal carcinoma, transthoracic esophagectomy is associated with high postoperative morbidity and mortality rates. The question of this study was whether an individualized preoperative risk analysis is able to predict postoperative outcome.

MATERIALS AND METHODS

Based on prospectively accumulated data of 126 patients with a malignant esophageal tumor, a preoperative composite risk score using objective parameters was evaluated. All patients underwent a transthoracic en bloc esophagectomy with two-field lymphadenectomy. The risk score was correlated to the postoperative course which was classified according to the days of intensive care unit (ICU) treatment, hours of mechanical ventilation, and reoperation and readmission to the ICU. A multivariate analysis was performed to identify single risk factors.

RESULTS

The overall morbidity rate was 55%, while the mortality rate was 5.6%. According to the composite risk score, 22.8% of the patients had a "low" risk, 53.2% had a "moderate" risk, and in 19% the preoperative risk was classified as "high". There was a significant correlation of the preoperative risk and the postoperative course (p<0.001). Multivariate analysis identified age, general status, and preoperative pulmonary function as independent risk factors of the postoperative outcome.

CONCLUSION

Preoperative risk analysis in particular pulmonary function and general status helps to select patients for transthoracic esophagectomy to reduce postoperative morbidity.

Significance of preoperative C-reactive protein as a parameter of the perioperative course and long-term prognosis in squamous cell carcinoma and adenocarcinoma of the oesophagus

AIM: C-reactive protein (CRP) is an acute-phase reactant and a known indicator of the malignant potential of the tumour. The aim of this study was to investigate the significance of preoperative CRP as a parameter of the perioperative course and long-term prognosis in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

METHODS: Serum CRP was determined preoperatively in 291 of 371 patients undergoing oesophagectomy for cancer from December 1989 to March 2004. Median patient age was 59 (28-79) year, 82.5% of patients were males. Squamous cell carcinoma was diagnosed in 151 (51.9%) and adenocarcinoma in 122 patients. Transhiatal oesophagectomy was done in 151 (51.9%) patients and 134 (46.0%) patients underwent the abdominothoracic procedure.

RESULTS: In 127 (43.6%) patients the preoperative serum CRP concentration was within the normal range (< 5 mg/dL), elevated CRP levels were measured in 164 (56.4%) patients. Tumour extension (P < 0.0005) and the number of lymph nodes affected by metastatic spread (P = 0.015) were significantly increased in the group with elevated CRP levels. Among the perioperative parameters both the number of blood transfusions (P = 0.006) and the general complication rate (P = 0.002) were higher in patients with elevated preoperative CRP levels. The long-term survival rate of 13.6 (0-109.8) mo was poorer in the group with elevated CRP levels compared to 18.9 (0-155.4) mo in the group with normal CRP levels (log-rank test: P = 0.107). Multivariate analysis with backward variables selection identified preoperative CRP as an independent prognostic factor of the long-term prognosis in patients with oesophageal carcinoma, with a hazard ratio of 1.182 (95% confidence interval: 1.030-1.356).

CONCLUSION: The preoperative serum CRP-level is an easily determined independent prognostic marker in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

Pulmonary complications in patients with chronic obstructive pulmonary disease following transthoracic esophagectomy

AIM: To investigate the incidence of various types of postoperative pulmonary complications (POPCs) and to evaluate the significance of perioperative arterial blood gases in patients with esophageal cancer accompanied with chronic obstructive pulmonary disease (COPD) after esophagectomy.

MEHTODS: Three hundred and fifty-eight patients were divided into POPC group and COPD group. We performed a retrospective review of the 358 consecutive patients after esophagectomy for esophageal cancer with or without COPD to assess the possible influence of COPD on postoperative pulmonary complications. We classified COPD into four grades according to percent-predicted forced expiratory volume in 1 s (FEV1) and analyzed the incidence rate of complications among the four grades. Perioperative arterial blood gases were tested in patients with or without pulmonary complications in COPD group and compared with POPC group.

RESULTS: Patients with COPD (29/86, 33.7%) had more pulmonary complications than those without COPD (36/272, 13.2%) (P < 0.001). Pneumonia (15/29, 51.7%), atelectasis (13/29, 44.8%), prolonged O₂ supplement (10/29, 34.5%), and prolonged mechanical ventilation (8/29, 27.6%) were the major complications in COPD group. Moreover, patients with severe COPD (gradeIIB, FEV1 < 50% of predicted) had more POPCs than those with moderate(gradeIIA, 50%-80% of predicted) and mild (gradeI≥ 80% of predicted) COPD (P < 0.05). PaO₂ was decreased and PaCO₂ was increased in patients with pulmonary complications in COPD group in the first postoperative week.

CONCLUSION: The criteria of COPD are the critical predictor for pulmonary complications in esophageal cancer patients undergoing esophagectomy. Severity of COPD affects the incidence rate of the pulmonary complication, and percent-predicted FEV1 is a good predictive variable for pulmonary complication in patients with COPD. Arterial blood gases are helpful in directing perioperative management.

Minimally invasive techniques for oesophageal cancer surgery

Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. The myriad of surgical approaches implies a lack of consensus on which is superior. Like open surgery, it is perhaps more important to have a tailored approach for the individual patient. MIS oesophagectomy has been shown to be feasible, and at least equivalent postoperative morbidity and mortality rates to open surgical resection have been demonstrated. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. Clear proof of superiority over conventional oesophagectomy methods however is not forthcoming since comparisons were often made with unmatched patient cohorts, and a well conducted randomized controlled trial has not been carried out. It is expected that with further improvements in instrumentation and experience, these difficult procedures may become more accessible and widely practised.

Predictors of operative death after oesophagectomy for carcinoma

BACKGROUND

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease.

METHODS

Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis.

RESULTS

The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death.

CONCLUSION

Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.

Morbidity and mortality after esophagectomy for esophageal carcinoma: a risk analysis

BACKGROUND

The study was aimed to identify pre- and intraoperative risk factors that potentially influence morbidity and mortality after esophagectomy for esophageal carcinoma with particular emphasis on the predominant tumor types.

PATIENTS AND METHODS

Between September 1985 and March 2004, 424 patients underwent esophagectomy for esophageal carcinoma. Of these, 186 (43.9%) patients had a transhiatal, and 231 (54.5%) patients underwent a transthoracic procedure with two-field lymphadenectomy. Pre-, intraoperative risk factors and tumor characteristics were included in the risk analysis to assess their influence on postoperative morbidity and mortality.

RESULTS

Multivariate analysis (logistic regression model) identified the surgical procedure as the most important risk factor for postoperative morbidity and mortality with the transthoracic technique associated with a significant higher risk. The comparison of the risk profile between the different histological tumor types, a significantly higher nutritional risk, poorer preoperative lung function and a higher prevalence of hepatopathy was observed in patients with squamous cell carcinoma (n = 229) compared to adenocarcinoma (n = 150) (p < 0.05). Although there was no significant difference in surgical complications between the two groups, the rate of general complications, length of postoperative intensive care unit-stay and mortality rate was significantly higher in patients with squamous cell carcinoma (p < 0.05).

CONCLUSION

The present risk analysis shows that the selection and the type of the surgical procedure are crucial factors for both the incidence of postoperative complications and the mortality rate. The higher risk of the transthoracic procedure is justified with a view to a better long term prognosis.

Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma

BACKGROUND

The aim of this study was to report the frequency of post-operative recurrent laryngeal nerve paralysis (RLNP) following resection for esophageal carcinoma.

PATIENTS AND METHODS

Four hundred and four patients were studied. Diagnosis of post-operative RLNP was performed by indirect laryngoscopy. Tumour characteristics, surgical approach and perioperative morbidity and mortality following esophageal resection were recorded.

RESULTS

Sixty patients were diagnosed with post-operative RLNP, of whom 47 had a unilateral and 16 a bilateral lesion. RLNP was more frequently diagnosed after transhiatal resection with cervical esophagogastrostomy as compared to abdomino-thoracic resection (p=0.06). A higher rate of post-operative pneumonia was evident in patients with RLNP (33 of 63 as opposed to 90 of 341; p=0.027).

CONCLUSION

RLNP is associated with a significant morbidity, especially pulmonary complications after resection of esophageal cancer.

Surgery for Esophageal Cancer after Concomitant Radiochemotherapy: Oncologic and Functional Results

The aim of this study was to evaluate the results of surgery after preoperative radiochemotherapy (PRCT) for esophageal cancer. This retrospective study included 88 patients scan between 1992 and 2000. The median follow-up was 55.7 months (3.3-104.1 months). Surgical mortality was 15.9%. Multivariate analysis found that the following were risk factors for surgical mortality: gamma-glutamyltransferase level > 75 UI/ml (p = 0.007), weight loss = 10% (p = 0.05), and digestive toxicity World Health Organization grade III or IV during PRCT (p = 0.019). The median overall survival was 24.9 months. The 5-year overall survival (OS) and disease-free survival (DFS) were, respectively, 33.1% and 33.2%. Complete responder patients had a 71.8% 5-year OS (p = 0.01) and a 71.8% 5-year DFS (p = 0.009). The rate of recurrence was 37.5%. Multivariate analysis found that female gender (p = 0.03), weight loss = 10% (p = 0.03), preoperative computed tomography scan bronchial contact (p = 0.01), and N+ status (pN+) at pathology examination (p = 0.0001) were predictors of poor oncologic results. Patients with high preoperative risk of surgical mortality need to be selected for intensive perioperative management. In association with surgery, PRCT improves the local control, DFS, and OS of responder patients. Morphologic evaluation for staging esophageal cancer in predicting the pathologic response after PRCT is poor or controversial. Only surgical resection can provide accurate prognostic information for staging esophageal cancer and improving local control.

Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer

OBJECTIVE

This study aimed at: (1) documenting the evolution of surgical results of esophagectomy in a high-volume center, (2) identifying predictive factors of pulmonary complications and mortality, and (3) examining whether preoperative chemoradiation therapy would complicate postoperative recovery.

SUMMARY BACKGROUND DATA

Pulmonary complications and mortality rate after esophagectomy remain substantial, and factors responsible have not been adequately studied. Neoadjuvant chemoradiation is widely used; it is hypothesized that this may lead to adverse postoperative outcome.

METHODS

Prospectively collected data were used to analyze outcome in 421 patients with intrathoracic squamous cell esophageal cancer who underwent resection. Logistic regression analyses determined independent predictors of pulmonary complications and death. Two time periods were compared: period I (January 1990 to June 1995) and period II (July 1995 to December 2001). In the later period, neoadjuvant chemoradiation therapy was introduced.

RESULTS

Transthoracic resections were carried out in 83% of patients. Neoadjuvant chemoradiation was given to 42% of patients in period II. Major pulmonary complications occurred in 15.9%, and were primarily responsible for 55% of hospital deaths. Thirty-day and hospital mortality rates were 1.4% and 4.8%, respectively. Logistic regression analysis identified age, operation duration, and proximal tumor location as risk factors for pulmonary complications, whereas advanced age and higher blood loss were predictive of mortality. Chemoradiation did not lead to worse outcome. When period I and II were compared, hospital mortality rate reduced from 7.8% to 1.1%, P = 0.001, with correspondingly less blood loss (median blood loss was 700 ml (range: 200-2700 (period I) and 450 ml (range: 100-7000) (period II), P < 0.01).

CONCLUSION

A 1.1% mortality rate was achieved in the last 6 years of the study period. Preoperative chemoradiation did not result in worse outcome. Reduction in mortality rate correlated with decreased blood loss.

Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer

BACKGROUND

Although local recurrence of advanced esophageal cancer is frequent after definitive chemoradiotherapy (CRT), the clinical benefit of salvage esophagectomy has not been elucidated.

METHODS

We reviewed 27 patients with squamous-cell cancer who underwent esophagectomy after definitive CRT (> or = 50 Gy) (salvage group) and 28 patients who underwent planned esophagectomy after neoadjuvant CRT (30 to 45 Gy) (neoadjuvant group).

RESULTS

The preoperative albumin level and vital capacity were significantly lower in the salvage group than in the neoadjuvant group. Two patients (7.4%) from the salvage group who underwent extended esophagectomy with three-field lymphadenectomy died of postoperative complications, but no deaths occurred after less-invasive surgery. There was no difference of overall postoperative survival between the salvage and neoadjuvant groups.

CONCLUSIONS

The outcome of salvage esophagectomy after definitive CRT was similar to that of planned esophagectomy after neoadjuvant CRT. Less-invasive procedures might be better for salvage esophagectomy because of the high operative risk.

Immunonutrition risk factors of respiratory complications after esophagectomy

BACKGROUND

There are many reports suggesting predictive factors for respiratory complications after esophagectomy, but few studies have focused on this problem from the aspect of immunonutrition.

METHODS

A series of 45 esophageal cancer patients who underwent potentially curative resection between April 1996 and March 2001 was enrolled in this study. Preoperative and intraoperative variables were analyzed for a correlation between risk factors and respiratory complications. In this study, immunonutrition variables as assessed by ultrasonography and indirect calorimetry were used. Uni- and multivariate analyses were performed to determine the predictive factors.

RESULTS

Of 45 patients, nine patients (20%) developed respiratory complications. In univariate analysis, forced expiratory volume in 1 s per body surface area (m(2)) in preoperative respiratory parameters, respiratory quotient, and caloric contributions of fat (percentage) and carbohydrate according to indirect calorimetry, and serum CH50 level significantly influenced the occurrence of postoperative respiratory complications. In multivariate analysis, the caloric contribution of fat (percentage) by indirect calorimetry and serum alpha(1)-antitrypsin (serine protease inhibitor) independently affected the occurrence of respiratory complications.

CONCLUSIONS

Preoperative excessive fat oxidation (potential starvation) and alpha(1)-antitrypsin were independent predictive factors for postoperative complications. Nutrition support such as enteral feeding to improve this malnourished state would reduce the incidence of postoperative respiratory complications.

Atrial fibrillation after esophagectomy is a marker for postoperative morbidity and mortality

OBJECTIVE

Postoperative atrial fibrillation complicates recovery in 20% to 25% of patients after esophagectomy for cancer. The purpose of this study is to understand this phenomenon.

METHODS

Between 1982 and 2000, 198 (22% of 921) patients had postoperative atrial fibrillation after esophagectomy. Propensity scoring and the Greedy Match algorithm were used to develop a cohort of control patients for statistical comparisons. One hundred forty-four patients who had postoperative atrial fibrillation were matched.

RESULTS

Pulmonary complications affected 42% of patients in the atrial fibrillation group compared with 17% in the control group (P <.001). Anastomotic leakage was more common in the atrial fibrillation group (6.9% vs 1.4%, P =.035). Surgical sepsis migrated with atrial fibrillation 4 times more frequently (P =.001). Multivariate analysis demonstrated that postoperative pulmonary complications (odds ratio, 2.5; 95% confidence interval, 1.42-4.3) and surgical sepsis (odds ratio, 3.4; 95% confidence interval, 1.2-9.6) were associated with postoperative atrial fibrillation. The mortality rates of the atrial fibrillation and control groups were 23% and 6.3%, respectively (P <.001). Median survival, excluding hospital deaths, was not different at 14.5 months (atrial fibrillation group) and 16.9 months (control group; P =.4).

CONCLUSION

Atrial fibrillation is a surrogate for surgical morbidity and mortality after esophagectomy. The occurrence of atrial fibrillation after esophageal resection should prompt not only the appropriate management of the arrhythmia but also a search for a more ominous underlying cause.

Analysis of pulmonary complications after three-field lymph node dissection for esophageal cancer

BACKGROUND

Pulmonary complications are a major component of morbidity and mortality after esophagectomy, and have not been well studied after extended lymphadenectomy.

METHODS

Four hundred forty-one patients underwent three-field lymph node dissection and were retrospectively reviewed. Pulmonary complications developed in 32 patients (7.3%) and resulted in 11 deaths (34.4% of pulmonary complications were fatal, and 62.4% of all mortality was caused by pulmonary complications). Pulmonary complications were divided into primary (group A) and secondary pulmonary morbidities (group B), and analyzed separately. Perioperative arterial blood gases on room air were compared with a matched control group (group C).

RESULTS

All primary complications occurred in the first postoperative week, whereas secondary complications were distributed evenly after operation. The incidence of serious infection (60% versus 23.5%, p = 0.041) and respiratory failure (70.6% versus 31.6%, p = 0.045) was significantly higher in group B as compared with group A and was associated with a higher death rate (47.1% versus 15.8%, p = 0.047). Changes in arterial blood gases were similar in groups A and C, both PaO(2) and pH were reduced in group B, and PaCO(2) was increased. Independent risk factors for primary pulmonary complications were history of major operation, abnormal spirometry, and chronic renal dysfunction. Predictive factors for secondary pulmonary complications were old age, concomitant total gastrectomy, major anastomotic leakage, and bilateral vocal cord palsy.

CONCLUSIONS

Pulmonary complications can be kept at a low level, but they still account for most of the mortality after three-field lymph node dissection. Primary and secondary pulmonary complications are two distinct entities that should be managed differently. Arterial blood gases on room air are helpful in the management of pulmonary complications.

Fundus rotation gastroplasty: rationale, technique and results

Anastomotic leakage is the main factor (up to 30%) for postoperative morbidity and mortality after esophageal resection. Compromised anastomotic perfusion after dissection of supplying vessels for gastric tube formation and tension on the suture line are the two main reasons for anastomotic insufficiency. To prevent anastomotic leakage, a new technique for gastric tube formation after esophageal resection has been developed and introduced into surgical practice: the fundus rotation gastroplasty (FRG). The following paper summarizes rationale, technique and early results of this new technique. It is shown that the FRG is a safe and effective technique for esophageal reconstruction and offers important advantages over conventional gastroplasties: (i). the improved perfusion of the oral part of the tube; (ii). the gain of tube length allowing for a safer performance of even pharyngeal anastomosis as shown by the low insufficiency rate of 9%; and (iii). the increase of remaining gastric reservoir supporting physiologic stomach and gut function. Therefore, the FRG seems to be an alternative and safe method for esophageal reconstruction, especially for high anastomotic locations.