Prediction of major pulmonary complications after esophagectomy

Impairment of perioperative activities of daily living is associated with poor prognosis following pancreatectomy for pancreatic cancer

PURPOSE

It has reported that the prevalence of frailty in patients with pancreatic cancer is 45%. The number of patients with pancreatic cancer is increasing, and within this cohort, patients often suffer from impaired activities of daily living (ADLs). This study aimed to examine the association between perioperative Barthel Index (BI) scores, a validated measure of ADLs, and survival outcomes after pancreatectomy for pancreatic cancer.

METHODS

We analyzed the data of 201 patients who underwent pancreatectomy for pancreatic cancer between 2010 and 2020. Preoperative and postoperative ADLs were assessed using the BI (range: 0-100; higher scores indicated greater independence). A preoperative or postoperative BI score ≤ 85 was defined as an impairment of perioperative ADLs. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) after adjusting for potential confounders.

RESULTS

Among the 201 patients, 14 (7.0%) had a preoperative BI score ≤ 85 and 50 (25%) had a postoperative BI score ≤ 85. Impairment of perioperative ADLs was independently associated with shorter overall survival (multivariable HR: 2.66, 95% confidence interval [95%CI]: 1.75-4.03, P < 0.001), cancer-specific survival (multivariable HR: 2.64, 95%CI: 1.15-4.25, P < 0.001), and recurrence-free survival (multivariable HR: 1.94, 95%CI: 1.08-3.50, P = 0.021).

CONCLUSION

Impairment of perioperative ADLs is associated with poor prognosis following pancreatectomy for pancreatic cancer. The maintenance and improvement of perioperative ADLs could play an important role in providing favorable long-term outcomes in patients with pancreatic cancer.

Minimally invasive versus open esophagectomy: Comparing the combined effects of smoking burden and operative approach on outcomes in esophagectomy

OBJECTIVE

To evaluate the interaction between smoking status and operative approach following esophagectomy on perioperative outcomes.

METHODS

Patients undergoing esophagectomy for esophageal cancer between January 1, 2009, and December 31, 2022, were identified from the STS-GTSD database and divided into 6 groups based on smoking status-never (NS), former (FS), or current (CS)-and surgical approach-minimally invasive (MIE) or open (OpenE). Primary outcomes were respiratory complications, operative mortality, major morbidity, and composite major morbidity and mortality.

RESULTS

The final study population comprised 27,373 patients (28.3% NS, 68.0% FS, and 13.7% CS) from 295 hospitals. Most cases were OpenE (58.1%), but the proportion of MIE increased from 19.2% in 2009 to 56.3% in 2022. Multivariable analysis showed that (1) risk-adjusted operative mortality was decreased only in never-smokers who underwent MIE (MIE-NS: adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI], 0.45-0.82), and; (2) there were no significant differences in mortality among the groups compared to the reference OpenE-NS group. Respiratory complications, major morbidity, and composite mortality and morbidity outcomes showed similar smoking and surgical approach effects. All outcomes were worse in smokers irrespective of approach, and within the same smoking status group, AORs for respiratory complications and morbidity were slightly lower in MIE versus OpenE, but these differences were nonsignificant.

CONCLUSIONS

Respiratory complications and other major morbidity outcomes following esophagectomy are substantially worsened by smoking history, particularly in current smokers. Among NS, MIE is associated with reduced operative mortality.

The effect of a pre- and post- operative exercise program versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): a randomized controlled trial

INTRODUCTION

Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window.

METHODS

A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery.

RESULTS

Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures.

CONCLUSIONS

This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT.

Pre- and intra-operative risk factors predict postoperative respiratory failure after minimally invasive oesophagectomy

OBJECTIVES

Severe pulmonary complications such as postoperative respiratory failure can occur after minimally invasive oesophagectomy. However, the risk factors have not been well identified. The goal of this study was to develop a predictive model for the occurrence of postoperative respiratory failure with a large sample.

METHODS

We collected data from patients with oesophageal cancer who had a minimally invasive oesophagectomy at Shanghai Chest Hospital from 2019 to 2022. Univariable and backward stepwise logistic regression analysis of 19 pre- and intra-operative factors was used before model fitting, and its performance was evaluated with the receiver operating characteristic curve. Internal validation was assessed with a calibration plot, decision curve analysis and area under the curve with 95% confidence intervals, obtained from 1000 resamples set by the bootstrap method.

RESULTS

This study enrolled 2,386 patients, 57 (2.4%) of whom developed postoperative respiratory failure. Backward stepwise logistic regression analysis revealed that age, body mass index, cardiovascular disease, diabetes, diffusion capacity of the lungs for carbon monoxide, tumour location and duration of chest surgery ≥101.5 min were predictive factors. A predictive model was constructed and showed acceptable performance (area under the curve: 0.755). The internal validation with the bootstrap method proves the good agreement for prediction and reality.

CONCLUSIONS

Obesity, severe diffusion dysfunction and upper segment oesophageal cancer were strong predictive factors. The established predictive model has acceptable predictive validity for postoperative respiratory failure after minimally invasive oesophagectomy, which may improve the identification of high-risk patients and enable health-care professionals to perform risk assessment for postoperative respiratory failure at the initial consultation.

Preoperative DLco and FEV1 are correlated with postoperative pulmonary complications in patients after esophagectomy

Limited information is available regarding the association between preoperative lung function and postoperative pulmonary complications (PPCs) in patients with esophageal cancer who undergo esophagectomy. This is a retrospective cohort study. Patients were classified into low and high lung function groups by the cutoff of the lowest fifth quintile of forced expiratory volume in 1 s (FEV1) %predicted (%pred) and diffusing capacity of the carbon monoxide (DLco) %pred. The PPCs compromised of atelectasis requiring bronchoscopic intervention, pneumonia, and acute lung injury/acute respiratory distress syndrome. Modified multivariable-adjusted Poisson regression model using robust error variances and inverse probability treatment weighting (IPTW) were used to assess the relative risk (RR) for the PPCs. A joint effect model considered FEV1%pred and DLco %pred together for the estimation of RR for the PPCs. Of 810 patients with esophageal cancer who underwent esophagectomy, 159 (19.6%) developed PPCs. The adjusted RR for PPCs in the low FEV1 group relative to high FEV1 group was 1.48 (95% confidence interval [CI] = 1.09-2.00) and 1.98 (95% CI = 1.46-2.68) in the low DLco group relative to the high DLco group. A joint effect model showed adjusted RR of PPCs was highest in patients with low DLco and low FEV1 followed by low DLco and high FEV1, high DLco and low FEV1, and high DLco and high FEV1 (Reference). Results were consistent with the IPTW. Reduced preoperative lung function (FEV1 and DLco) is associated with post-esophagectomy PPCs. The risk was further strengthened when both values decreased together.

Complication Prediction after Esophagectomy with Machine Learning

Esophageal cancer can be treated effectively with esophagectomy; however, the postoperative complication rate is high. In this paper, we study to what extent machine learning methods can predict anastomotic leakage and pneumonia up to two days in advance. We use a dataset with 417 patients who underwent esophagectomy between 2011 and 2021. The dataset contains multimodal temporal information, specifically, laboratory results, vital signs, thorax images, and preoperative patient characteristics. The best models scored mean test set AUROCs of 0.87 and 0.82 for leakage 1 and 2 days ahead, respectively. For pneumonia, this was 0.74 and 0.61 for 1 and 2 days ahead, respectively. We conclude that machine learning models can effectively predict anastomotic leakage and pneumonia after esophagectomy.

Clinical Outcomes of Preserving Bronchial Arteries During Radical Esophagectomy: A Propensity-Score Matched Analysis

BACKGROUND

Postoperative pneumonia is a common and major cause of mortality after radical esophagectomy. Intraoperative preservation of the bronchial arteries is often aimed at avoiding tracheobronchial ischemia; however, it is unknown whether this contributes to a reduction in postoperative pneumonia.

PATIENTS AND METHODS

We enrolled 348 consecutive patients who underwent radical esophagectomy for esophageal cancer at Toranomon Hospital from January 2011 to July 2018. We classified patients into a bronchial artery-resected (BA-R) group (n = 93) and a bronchial artery-preserved (BA-P) group (n = 255) and compared the incidence of postoperative pneumonia between the two groups. A propensity score-matching analysis for bronchial artery preservation versus resection was performed.

RESULTS

Overall, 182 patients were matched. Univariate analysis of the propensity score-matched groups showed that Brinkman index ≥ 400, vital capacity (%VC) < 80%, and bronchial artery resection were associated with the development of postoperative pneumonia. Multivariate analysis revealed three significant factors associated with postoperative pneumonia: Brinkman index ≥ 400 [p = 0.006, odds ratio (HR) 3.302, 95% confidence interval (95% CI) 1.399-7.790], %VC < 80% (p = 0.034, HR 6.365, 95% CI 1.151-35.205), and bronchial artery resection (p = 0.034, HR 2.131, 95% CI 1.060-4.282). The incidence of postoperative complications (CD grade III) was higher in the BA-R group (BA-R 42.8% versus BA-P 27.5%, p = 0.030). There was no significant difference in overall survival between the two groups at 5 years (BA-R 63.1% versus BA-P 72.1%, p = 0.130).

CONCLUSION

Preserving the bronchial artery is associated with a decreased incidence of postoperative pneumonia.

Effect of Neoadjuvant Immunotherapy Combined with Chemotherapy on Pulmonary Function and Postoperative Pulmonary Complications in Esophageal Cancer: A Retrospective Study

BACKGROUND

Neoadjuvant immunotherapy, targeting the PD-1 or PD-L1, combined with chemotherapy (NICT), can improve the radical resection and survival rates for locally advanced EC. However, it may impair pulmonary function, and the effect of NICT on pulmonary function and postoperative pulmonary complications in EC patients remains unknown. This study aimed to investigate whether NICT can affect pulmonary functions and postoperative pulmonary complications in EC patients.

METHODS

The study retrospectively recruited 220 EC patients who received NICT at the Department of Esophageal Cancer in Tianjin Medical University Cancer Institute & Hospital from January 2021 to June 2022. Changes in pulmonary function before and after NICT were compared. Logistic regression analysis was performed to analyze the correlations of pulmonary functions and clinical characteristics with postoperative pulmonary complications, respectively.

RESULTS

The FEV1% pred, FVC, FVC% pred, and FEV1/FVC% significantly increased after NICT, with a P-value of 0.018, 0.005, 0.001, and 0.036, respectively. In contrast, there was a significant decline in the DLCO (8.92 ± 2.34 L before NICT vs. 7.79 ± 2.30 L after NICT; P < 0.05) and DLCO% pred (102.97 ± 26.22% before NICT vs. 90.18 ± 25.04% after NICT; P < 0.05). High DLCO and DLCO% pred at baseline levels were risk factors for DLCO reduction in EC patients after NICT. Advanced age, smoking history, FEV1% pred after NICT, and FVC% pred baseline and after therapy were risk factors for postoperative pulmonary complications, with a P-value of 0.043, 0.038, 0.048, 0.034, and 0.004, respectively. Although the DLCO level decreased after NICT, it did not increase the incidence of postoperative pulmonary complications.

CONCLUSION

NICT may improve pulmonary ventilation function but also lead to a decrease in DLCO and DLCO% pred in EC patients. Nevertheless, the decreased DLCO after NICT did not increase the risk of postoperative pulmonary complications.

Single-Stage Surgical Procedure for Patients with Primary Esophageal and Lung Cancers

BACKGROUND

 The aim of this study was to evaluate the safety and feasibility of simultaneous surgery for patients with primary esophageal and lung cancers.

METHODS

 Patients with primary esophageal and lung cancers who underwent simultaneous surgical procedures between January 2016 and January 2022 were retrospectively analyzed. The data of patients who underwent esophagectomy and lobectomy (group EL) were compared with those of patients who underwent esophagectomy and sublobar resection (group ES).

RESULTS

 A total of 21 patients were included with an average age of 64.62 ± 5.24 years. Group EL contained 8 patients and group ES contained 13 patients. All procedures were completed uneventfully with a mean operative time of 251.19 ± 66.93 minutes. Pulmonary complications occurred in six (28.57%) patients. Other complications included anastomotic leakage in 1 patient, pleural effusion requiring drainage in 8 patients, atrial fibrillation in 2 patients, and incision infection in 1 patient. All patients were followed up for 30.23 ± 21.82 months. During the follow-up period, nine patients had a recurrence of cancer and died of tumor progression, and one patient died of a tracheothoracogastric fistula. Complications and mortality in group EL did not increase when compared to those in group ES.

CONCLUSION

 It is safe and feasible to perform a single-stage surgical procedure for patients with primary esophageal and lung cancers. Simultaneous esophagectomy and lobectomy did not increase postoperative complications or mortality compared with esophagectomy and sublobar resection.

Evidence-based Practice Interventions for Reducing Postoperative Pulmonary Complications: A Narrative Review

Background

Specific surgical procedures, such as upper abdominal and thoracic surgery, are connected to an increased predisposition of postoperative pulmonary complications (PPCs). The incidence of PPCs could vary approximately between 20-90% with upper abdominal surgery, which can be minimized by using treatment procedures that increase lung capacity and encourage inspiration. This review aims to examine the effectiveness of already existing evidence-based interventions that promote lung expansion, thereby preventing PPCs.

Method

We mainly focused on the existing evidence of preoperative education on the incentive spirometer, early mobilization, directed coughing, deep breathing exercises, chest physiotherapy, and inspiratory muscle training (IMT) to prevent PPCs. The literature search was limited to experimental, observational studies, systemic reviews, and articles published in the last 15 years, January 2007- Dec. 2022, in PubMed and Google Scholar.

Result

This initial search yielded a total of 5301 articles. All articles with titles not related to the topic were eliminated. 1050 records were screened, and the final review was conducted with 22 articles, including 13 randomized controlled trials (RCTs), four systemic reviews, one retrospective review, three observational studies, and one non-experimental study. Our review reveals mixed evidence for individual interventions, including but not limited to incentive spirometry, inspiratory muscle training, early mobilization, cough, deep breathing, etc. Some studies maintain that intervention is effective; others imply there is no substantial difference in the choice of intervention.

Conclusion

The literature review concluded that patients who received multiple interventions showed significant improvement in pulmonary function postoperatively. However, definitive studies need to be conducted to solidify this conclusion.

Correlation of Preoperative Anemia Subtypes with Tumor Characteristics, Systemic Inflammation and Immediate Postoperative Outcomes in Gastrointestinal Cancer Patients - A Prospective Observational Study

PURPOSE

Patients with gastrointestinal (GI) malignancies more frequently present with anemia. A large proportion of them exhibit a systemic inflammatory response causing anemia of chronic disease. Although tumor factors play an essential role in determining the prognosis, studies have also reported the role of host factors in the outcome. This study was done to determine the association between systemic inflammation, tumor characteristics, and immediate postoperative outcome among various anemia subgroups.

METHODS

This was a single-center, prospective observational study of patients undergoing treatment for GI cancers. The modified Glasgow Prognostic Score (mGPS) was calculated, and patients were followed up until discharge regarding postoperative complications, length of the hospital, ICU stay, and mortality. The patient demographics, tumor characteristics, systemic inflammation, and postoperative complications were studied among different subtypes of anemia.

RESULTS

A total of 209 patients were analyzed, and a higher prevalence of normocytic anemia (52.63%) and systemic inflammatory response (62.21%) was observed among the study population. Systemic inflammation was significantly associated with a higher nodal stage (p = 0.02) and margin positivity (p = 0.006). Patients with higher mGPS had significantly higher requirements for blood transfusion (p = 0.003), superficial SSI (p = 0.03), and sepsis (p = 0.02); however, other postoperative complications were comparable among patients without an inflammatory response.

CONCLUSION

Higher prevalence of normocytic anemia is observed among patients with gastrointestinal cancer. Normocytic anemia is significantly associated with systemic inflammation with no significant difference in tumor characters and immediate postoperative outcomes.

A Comparison of Two Methods of Pre-operative Inspiratory Muscle Training on Post-operative Outcome Following Esophagectomy

Esophageal carcinoma is a multifaceted and complex disease of rapidly rising incidence that exerts an increasing social and financial burden on global healthcare systems. Esophagectomy is associated with high rates of peri- and post-operative morbidity and mortality because of complex anatomy, frail health of patients, and late diagnosis of the disease. The most common complication seen is post-operative pulmonary complication (PPC). This study was planned to compare and analyze the outcome of two different protocols of preoperative IMT program on the rate of PPCs in patients undergoing esophagectomy. Twenty patients who underwent esophagectomy for carcinoma esophagus were included in the study and were randomly divided into 2 groups of 10 each. Group A received IMT-HI training for 4 weeks, whereas the group B received IMT-E training for 4 weeks pre-operatively. All the patients included in the study underwent a baseline pulmonary assessment which included pulmonary function test (FVC, FEV1, and FEV1/FVC), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). Four-week preoperative IMT-HI lead to better outcome following esophagectomy as compared to IMT-E. Relative risk of PPC was 4:1 (IMT-E:IMT-HI). However, there was no statistically significant improvement in PFTs, MEP, and MIP from baseline or between two groups. The difference in PPC in two groups did not reach statistical significance despite the fact that relative risk of PPC was 4:1 (IMT-E:IMT-HI).

Association of DLT versus SLT with postoperative pneumonia during esophagectomy in China: a retrospective comparison study

BACKGROUND

Double lumen tube (DLT) and single lumen tube (SLT) are two common endotracheal tube (ETT) types in esophageal cancer surgery. Evidence of the relationship between two ETT types and postoperative pneumonia (PP) remains unclear. We aimed to determine the association between two types of ETT (DLT and SLT) and PP and assess the perioperative risk-related parameters that affect PP.

METHODS

This study included 680 patients who underwent esophageal cancer surgery from January 01, 2010 through December 31, 2020. The primary outcome was PP, and the secondary outcome was perioperative risk-related parameters that affect PP. The independent variable was the type of ETT: DLT or SLT. The dependent variable was PP. To determine the relationship between variables and PP, univariate and multivariate analyses were performed. The covariables included baseline demographic characteristics, comorbidity disease, neoadjuvant chemotherapy, tumor location, laboratory parameters, intraoperative related variables.

RESULTS

In all patients, the incidence of postoperative pneumonia in esophagectomy was 32.77% (36.90% in DLT group and 26.38% in SLT group). After adjusting for potential risk factors, we found that using an SLT in esophagectomy was associated with lower risk of postoperative pneumonia compared to using a DLT (Odd ratio = 0.41, 95% confidence interval (CI): 0.22, 0.77, p = 0.0057). Besides DLT, smoking history, combined intravenous and inhalation anesthesia (CIIA) and vasoactive drug use were all significant and independent risk factors for postoperative pneumonia in esophagectomy. These results remained stable and reliable after subgroup analysis.

CONCLUSIONS

During esophagectomy, there is significant association between the type of ETT (DLT or SLT) and PP. Patients who were intubated with a single lumen tube may have a lower rate of postoperative pneumonia than those who were intubated with a double lumen tube. This finding requires verification in follow-up studies.

Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study

BACKGROUND

The degree of difficulty in the overall procedure and forceps handling encountered by surgeons is greatly influenced by the positional relationship of intrathoracic organs in minimally invasive esophagectomy. This study aimed to identify the anatomical factors associated with the difficulty of minimally invasive esophagectomy assessed by intraoperative injuries and postoperative outcomes.

METHODS

Minimally invasive esophagectomy in the left-decubitus position was performed in 258 patients. We defined α (mm) as the anteroposterior distance between the front of the vertebral body and aorta, β (mm) as the distance between the center of the vertebral body and center of the aorta, and γ (degree) as the angle formed at surgeon's right-hand port site by insertion of lines from the front of aorta and from the front of vertebrae in the computed tomography slice at the operator's right-hand forceps hole level. We retrospectively analyzed the correlations among clinico-anatomical factors, surgeon- or assistant-caused intraoperative organ injuries, and postoperative complications.

RESULTS

Intraoperative injuries significantly correlated with shorter α (0.2 vs. 3.9), longer β (33.0 vs. 30.5), smaller γ (3.0 vs. 4.3), R1 resection (18.5% vs. 8.3%), and the presence of intrathoracic adhesion (46% vs. 26%) compared with the non-injured group. Division of the median values into two groups showed that shorter α and smaller γ were significantly associated with organ injury. Longer β was significantly associated with postoperative tachycardia onset, respiratory complications, and mediastinal recurrence. Furthermore, the occurrence of intraoperative injuries was significantly associated with the onset of postoperative pulmonary complications.

CONCLUSIONS

Intrathoracic anatomical features greatly affected the procedural difficulty of minimally invasive esophagectomy, suggesting that preoperative computed tomography simulation and appropriate port settings may improve surgical outcomes.

Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon

BACKGROUND

Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models.

METHODS

Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes.

RESULTS

Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models.

CONCLUSION

Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.

Preoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND

Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making.

AIM

To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness.

RESULTS

The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness.

CONCLUSION

Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.

Effects of Multimodal Inpatient Rehabilitation vs Conventional Pulmonary Rehabilitation on Physical Recovery After Esophageal Cancer Surgery

OBJECTIVE

To determine the effects of multimodal rehabilitation initiated immediately after esophageal cancer surgery on physical recovery compared with conventional pulmonary rehabilitation.

DESIGN

Retrospective study.

SETTING

Private quaternary care hospital.

PARTICIPANTS

Fifty-nine inpatients (N=59) who participated in either conventional pulmonary rehabilitation (n=30) or in multimodal rehabilitation (n=29) after esophageal cancer surgery were included.

INTERVENTIONS

Both groups performed pulmonary exercises, including deep breathing, chest expansion, inspiratory muscle training, coughing, and manual vibration. In the conventional pulmonary rehabilitation group, light-intensity mat exercise, stretching, and walking were performed. The multimodal rehabilitation group performed resistance exercises and moderate- to high-intensity aerobic interval exercises using a bicycle.

MAIN OUTCOME MEASURES

The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30), pain, 6-minute walk test (6MWT), 30-second chair stand test, and grip strengths were assessed before and after the rehabilitation programs.

RESULTS

Symptom scales of pain, dyspnea, and insomnia in the EORTC QLQ-C30 as well as 6MWT improved significantly after each program (P<.05). 6MWT (73.1±52.6 vs 28.4±14.3, P<.001, d=1.15), 30-second chair stand test (3.5±3.9 vs 0.35±2.0, P<.001, d=1.06), and left grip strength (1.2±1.3 vs 0.0±1.5, P=.002, d=0.42) improved significantly in the multimodal rehabilitation group compared with the pulmonary rehabilitation group. While right grip strength also showed more improvement for those undergoing the multimodal program, the mean strength difference was not clinically meaningful.

CONCLUSIONS

A multimodal inpatient rehabilitation program instituted early after esophageal cancer surgery improved endurance for walking more than conventional pulmonary rehabilitation as measured by the 6MWT and the 30-second chair stand test.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

A novel nomogram predicting the risk of postoperative pneumonia for esophageal cancer patients after minimally invasive esophagectomy

BACKGROUND

Pneumonia is a common complication after minimally invasive esophagectomy (MIE), which prolongs hospital stay, adding to the cost and increasing the risk to patients' lives. This study aimed to identify risk factors and establish a predictive nomogram for postoperative pneumonia (PP).

METHODS

This case control study included 609 patients with esophageal cancer who underwent MIE between March 2015 and August 2019 in Cancer Hospital, Chinese Academy of Medical Sciences. We randomly divided the data into training and validation sets in the ratio of 7:3 and performed univariate and multivariate logistic regression analyses to acquire independent risk factors of the training set. We constructed a nomogram based on the independent risk factors. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) plots were used to evaluate the discrimination of the nomogram. Validation set was applied to confirm the predictive value of the nomogram.

RESULTS

In the univariate analysis, age, gender, abdominal procedure method, thoracic operative time, duration of chest tube placement, anastomotic leakage, and recurrent laryngeal nerve palsy were found to be correlated with the incidence of PP. In multivariate analysis, all variables except thoracic operative time were found to be independent risk factors for PP. A nomogram was constructed based on these independent risk factors. The C-index of the training and validation sets was 0.769 and 0.734, respectively, and the areas under the curve (AUC) of ROC curves of the training and validation sets were 0.769 and 0.686, respectively. The calibration plots and DCA plots of the training and validation sets showed the accuracy and predictive value of the nomogram.

CONCLUSION

The nomogram could accurately identify the risk factors for PP. We could predict the occurrence of PP based on this nomogram and take corresponding measures to reduce the incidence of PP.

Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion

Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.

Prognostic Value of Pretreatment Red Blood Cell Distribution Width in Patients With Esophageal Cancer Who Underwent Esophagectomy: A Retrospective Study

Objective

This comprehensive analysis aimed to elucidate the mechanism underlying how high pretreatment red blood cell distribution width (RDW) reflects poor prognosis after esophagectomy for esophageal cancer.

Background

Several cohort studies have reported that preoperative RDW might be a predictive marker for poor prognosis after esophagectomy; however, the underlying mechanism of this relationship has not been elucidated.

Methods

This study included 626 patients with esophageal cancer who underwent esophagectomy between April 2005 and November 2020. A retrospective investigation of the association between pretreatment RDW and clinicopathological features, blood data, short-term outcomes, and prognosis was conducted using a prospectively entered institutional clinical database and the latest follow-up data.

Results

Of 626 patients, 87 (13.9%) had a high pretreatment RDW. High RDW was significantly associated with several disadvantageous characteristics regarding performance status, the American Society of Anesthesiologists physical status, respiratory comorbidity, and nutritional status. Similarly, high RDW correlated with frequent postoperative morbidities (respiratory morbidity and reoperation; P = 0.022 and 0.034, respectively), decreased opportunities for adjuvant chemotherapy (P = 0.0062), and increased death from causes other than esophageal cancer (P = 0.046). Finally, RDW could be an independent predictor of survival after esophagectomy (hazard ratio, 1.47; 95% confidence interval, 1.009-2.148; P = 0.045).

Conclusion

High pretreatment RDW reflected various adverse backgrounds and it could be a surrogate marker of poor prognosis in patients who have undergone esophagectomy for esophageal cancer.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery.

METHODS

We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy).

RESULTS

46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry).

CONCLUSION

As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.

Clinical analysis of patients with respiratory failure after esophageal cancer operation

Background

To explore the clinical profiles and outcomes of patients with acute respiratory failure (ARF) after esophagectomy.

Methods

We retrospectively analyzed cases of patients who had been diagnosed with ARF after esophagectomy and compared survivors with non-survivors to explore the risks that may affect their outcomes.

Results

In total, 62 patients were admitted to the intensive care unit (ICU) with ARF after esophagectomy between January 1, 2010, and December 31, 2017. Of these patients, 69.4% needed mechanical ventilation, with an average time on the ventilator of 304 hours (304.33±374.37 hours). The average length of stay in the ICU and in the hospital were 14 days (14.48±17.64 days) and 50 days (50.15±37.28 days), respectively. Mortality in the ICU and 90 days after the operation was 6.5% and 16.1%, respectively. Compared with the survivors, the 90-day post-operative non-survivors had a poorer N stage in the TNM classification system. The causes of ARF included anastomotic leakage, pneumonia, vocal cord paralysis, sputum plugging, pulmonary embolism (PE), and acute respiratory distress syndrome (ARDS). ARF induced by different factors occurred at different times and had different outcomes. The three most common reasons for mortality in the ICU were ARDS (33.33%), anastomotic leakage (11.76%), and pneumonia (10%). The three most common reasons for mortality in the 90-day post-operative period were pneumonia (40%), anastomotic leakage (23.53%), and ARDS and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) (33.33%).

Conclusions

Anastomotic leakage, pneumonia, ARDS, and AECOPD were the main causes of death in ARF patients after esophagectomy. We found that the N stage in the TNM classification system may affect 90-day post-operative mortality in these patients.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

The effect of age on short-term and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy: a propensity score-matched analysis

Background

The number of elderly patients diagnosed with esophageal cancer rises. Current information about outcomes in elderly patients undergoing thoracoscopic Ivor Lewis esophagectomy is limited. The objective of this study was to evaluate the influence of age on short-and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy.

Methods

A retrospective review of 188 patients with esophageal cancer undergoing thoracoscopic Ivor Lewis esophagectomy between August 2014 and July 2019 was performed. Patients were divided into patients aged > 75 years (elderly group (EG), n = 37) and patients ≤ 75 years (younger group (YG), n = 151) and matched using propensity-score matching. Baseline characteristics, length of hospital stay, mortality and major postoperative complications (Clavien-Dindo ≥ grade III) were compared.

Results

After matching 74 patients remained (n = 37 in each group). Postoperatively, no significant differences in major and overall complications, intra-hospital and 30-day mortality, disease-free or overall survival up to 3 years after surgery were noted. The incidence of pulmonary complications (65% vs. 38%) and pneumonia (54% vs. 30%) was significantly higher and the median hospital length of stay (12 vs. 14 days) significantly longer in the EG versus YG.

Conclusion

Thoracoscopic Ivor Lewis esophagectomies resulted in acceptable postoperative major morbidity and mortality without compromising 3-years overall and disease-free survival in elderly compared to younger patients with esophageal cancer. However, the incidence of postoperative pulmonary complications was higher in patients aged over 75 years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01435-5.

Preoperative transferrin level is a novel indicator of short- and long-term outcomes after esophageal cancer surgery

BACKGROUND

This study aimed to examine whether preoperative serum transferrin, a rapid-turnover protein, correlates with short- and long-term outcomes after esophagectomy.

METHODS

Preoperative transferrin levels, calculated by summing serum iron and unsaturated iron-binding capacity, were evaluated in 224 patients who underwent esophagectomy for stage I-III esophageal cancer without preoperative treatment. Transferrin levels are directly proportional to total iron-binding capacity (TIBC), and we defined TIBC < 250 μg/dL as low transferrin. We evaluated the relationship between preoperative transferrin levels and short- and long-term outcomes after esophagectomy using univariate and multivariate Cox proportional hazards analyses.

RESULTS

Of all patients, 25 (11.2%) had low preoperative transferrin levels. Low preoperative transferrin levels were strongly correlated with worse preoperative performance status, advanced pathological T stage, and more open esophagectomy (p = 0.0078, 0.0001, and 0.013, respectively). Patients with low preoperative transferrin levels experienced significantly more frequent postoperative pneumonia in univariate and multivariate analysis [hazard ratio (HR) 3.30, 95% confidence interval (CI) 1.032-10.033, p = 0.0443]. Additionally, these patients were significantly correlated with worse overall survival (OS) in univariate and multivariate analyses (HR 2.75, 95% CI 1.018-7.426, p = 0.0460). Furthermore, we investigated the relationship between OS and postoperative pneumonia to elucidate why low preoperative transferrin, which is an independent risk factor for postoperative pneumonia, leads to poor prognosis. Patients with postoperative pneumonia were strongly associated with a shorter OS (p = 0.0099).

CONCLUSION

Preoperative serum transferrin levels may be a novel indicator of postoperative pneumonia and OS after esophagectomy.

Development and validation of a nomogram to predict overall survival of T1 esophageal squamous cell carcinoma patients with lymph node metastasis

PURPOSE

To develop a nomogram for predicting the prognosis of T1 esophageal squamous cell carcinoma (ESCC) patients with positive lymph node.

METHODS

T1 ESCC patients with lymph node metastasis diagnosed between 2010 and 2015 were selected from the Surveillance, Epidemiology, and Final Results (SEER) database. The entire cohort was randomly divided in the ratio of 7:3 into a training group (n=457) and validation group (n=192), respectively. Prognostic factors were identified by univariate and multivariate Cox regression models. Harrell's concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve were used to evaluate the discrimination and calibration of the nomogram. The accuracy and clinical net benefit of the nomogram compared with the 7^th AJCC staging system were evaluated using net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA).

RESULTS

The nomogram consisted of eight factors: insurance, T stage, summary stage, primary site, radiation code, chemotherapy, surgery, and radiation sequence with surgery. In the training and validation cohorts, the AUCs exceeded 0.700, and the C-index scores were 0.749 and 0.751, respectively, indicating that the nomogram had good discrimination. The consistency between the survival probability predicted by the nomogram and the actual observed probability was indicated by the calibration curve in the training and validation cohorts. For NRI>0 and IDI>0, the predictive power of the nomogram was more accurate than that of the 7^th AJCC staging system. Furthermore, the DCA curve indicated that the nomogram achieved better clinical utility than the traditional system.

CONCLUSIONS

Unlike the 7^th AJCC staging system, the developed and validated nomogram can help clinical staff to more accurately, personally and comprehensively predict the 1-year and 3-year OS probability of T1 ESCC patients with lymph node metastasis.

Risk of Acute Lung Injury after Esophagectomy

To develop a new approach for identifying acute lung injury (ALI) in surgical ward setting and to assess incidence rate, clinical outcomes, and risk factors for ALI cases after esophagectomy. We also compare the degree of lung injury between operative and non-operative sides. Consecutive esophageal cancer patients (n=1022) who underwent esophagectomy from Dec 2012 to Nov 2018 in our hospital were studied. An approach for identifying ALI was proposed that integrated radiographic assessment of lung edema (RALE) score to quantify degree of lung edema. Stepwise logistic regression identified risk factors for postoperative ALI incidence. The degree of bilateral lung injury was compared using the RALE score. The approach for identifying ALI in surgical ward setting was defined as acute onset, PaO₂/FiO₂≤300 mmHg, bilateral opacities on bedside chest radiograph with a RALE score≥16, and exclusion of cardiogenic pulmonary edema. Incidence rate of ALI was estimated to be 9.7%. ALI diagnosis was associated with multiple clinical complications, prolonged hospital stay, higher medical bills, and higher perioperative mortality. Nine risk factors including BMI, ASA class, DLCO%, duration of surgery, neutrophil percentage, high-density lipoprotein, and electrolyte disorders were identified. The RALE score of the lung lobes of the operative side was higher than the non-operative side. A new approach for identifying ALI in esophageal cancer patients receiving esophagectomy was proposed and several risk factors were identified. ALI is common and has severe outcomes. The lung lobes on the operative side are more likely to be affected than the non-operative side.

Airflow Limitation Predicts Postoperative Pneumonia after Esophagectomy

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is known to be a risk factor of pneumonia after esophagectomy. In this study, we investigated the relationship of airflow limitation with the occurrence and the severity of pneumonia in esophageal cancer patients who underwent esophagectomy.

METHODS

We enrolled 844 patients who underwent curative esophagectomy between 2009 and 2018. The airflow limitation was evaluated using the percent-predicted forced expiratory volume at 1 s (%FEV1) with spirometry.

RESULTS

There were 597 (70.7%), 141 (16.7%), 68 (8.1%), and 38 patients (4.5%) with %FEV1 of ≥ 90%, 80-90%, 70-80%, and < 70% categories, respectively. One hundred and ninety-one patients (22.6%) occurred pneumonia, and the incidences of pneumonia in each category of patients were 18.8%, 28.4%, 29.4%, and 50.0%, respectively. In multivariate analysis, the categories of 80%-90%, 70-80%, and < 70% were significantly associated with a higher incidence of postoperative pneumonia (OR 1.57; 95% CI 1.02-2.43, OR 1.87; 95% CI 1.04-3.36, OR 3.34; 95% CI 1.66-6.71, respectively), with the %FEV1 category of ≥ 90% as reference. The incidence of severe pneumonia of Clavien-Dindo grade III or higher was also significantly associated with the %FEV1. In patients without COPD, the incidence of pneumonia was significantly higher in those with %FEV1 < 90% than in those with %FEV1 ≥ 90% (32.2% versus 17.5%, p < 0.001).

CONCLUSIONS

The airflow limitation can help predict the occurrence of pneumonia after esophagectomy in patients with and without COPD. Exclusive preventive measures should be considered in patients with reduced %FEV1 undergoing esophagectomy.

The Effect of Balloon-Blowing Exercise on Postoperative Pulmonary Functions in Patients Undergoing Total Hip Arthroplasty

General anesthesia, prolonged immobilization, and pain may adversely affect pulmonary function in patients undergoing prosthetic surgery. The aim of this study was to evaluate the effect of balloon-blowing exercises on pulmonary functions in patients undergoing total hip arthroplasty. The patients in the experimental group performed three sets of balloon-blowing exercises in the morning, at noon, and in the evening on the first to third days postoperatively. The increase in forced vital capacity (FVC) values between the control and experimental groups in the postoperative period was statistically significant (p < .001), in favor of the experimental group. The increase in forced expiratory volume during the first second (FEV1)/FVC ratio was found to be significantly higher in the experimental group than in the control group (p < .001). Patients who performed balloon-blowing exercises increased their FVC and FEV1/FVC ratio.

Postoperative pneumonia in the acute phase is an important prognostic factor in patients with esophageal cancer

BACKGROUND

The impact of pneumonia on prognosis is controversial, and no report has focused on its onset. This study aimed to examine the impact of pneumonia according to its onset on prognosis and its associated risk factors after esophagectomy.

METHODS

In total, 484 patients who underwent curative resection for esophageal squamous cell carcinoma were retrospectively reviewed. Patients with pneumonia were divided into two groups by the date of onset: pneumonia in the acute phase within 7 days after surgery (n = 59) and pneumonia in the subacute phase 8 days after surgery (n = 49).

RESULTS

The disease-free survival of patients with acute pneumonia was significantly lower than that of those without pneumonia (P = .0002), whereas the disease-free survival of patients with subacute pneumonia was similar to that of patients without pneumonia (P = .5363). In multivariate analysis for disease-free survival, P-stage III to IV (hazard ratio [HR], 3.344; P < .0001), transfusion (HR, 1.4078; P = .0291), and acute pneumonia (HR, 1.8463; P = .0009) were independent prognostic factors. Multivariate analysis revealed that age >75 years (odds ratio [OR], 2.1746; P = .0232), respiratory disease comorbidity (OR, 4.3869; P = .0002), cT3-4 (OR, 2.0143; P = .0477), extended surgery duration (OR, 2.3406; P = .0152), and posterior mediastinal reconstruction (OR, 0.1432; P = .0439) were independent risk factors for acute pneumonia.

CONCLUSION

Post-esophagectomy pneumonia in the acute phase was an independent prognostic factor, whereas advanced age, respiratory disease comorbidity, and extended surgery duration were risk factors for acute pneumonia.

Respiratory complications after surgery in Vietnam: National estimates of the economic burden

Background

Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.

Methods

We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.

Findings

Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.

Interpretation

The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.

Funding

The authors did not receive any funds for conducting this study

Impact of Smoking Status on Perioperative Morbidity, Mortality, and Long-Term Survival Following Transthoracic Esophagectomy for Esophageal Cancer

Introduction

Esophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy.

Objective

This study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer.

Methods

Consecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]).

Results

During the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses.

Conclusion

Although smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09720-6.

Preoperative maximal voluntary ventilation, hemoglobin, albumin, lymphocytes and platelets predict postoperative survival in esophageal squamous cell carcinoma

BACKGROUND

Preoperative pulmonary function plays an important role in selecting surgical candidates and assessing postoperative complications. Reduced pulmonary function is associated with poor survival in several cancers, but the prognostic value of preoperative pulmonary function in esophageal squamous cell carcinoma (ESCC) is unclear. Nutritional and systemic inflammation parameters are vital to cancer survival, and the combination of these parameters improves the prognostic value. The hemoglobin, albumin, lymphocytes and platelets (HALP) score is a novel prognostic indicator to reflect the nutritional and inflammation status, but the clinical effects of the HALP score combined with maximal voluntary ventilation (MVV), an important parameter of pulmonary function, have not been well studied in ESCC.

AIM

To investigate the prognostic value of MVV and HALP score for assessing postoperative survival of ESCC patients.

METHODS

Data from 834 ESCC patients who underwent radical esophagectomy with R0 resection were collected and retrospectively analyzed. Preoperative MVV and HALP data were retrieved from medical archives. The HALP score was calculated by the formula: Hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L)/platelets (/L). The optimal cut-off values of MVV and HALP score were calculated by the receiver operating characteristic curve analysis. The Kaplan-Meier method with log-rank test was used to draw the survival curves for the variables tested. Multivariate Cox proportional hazard regression models were used to analyze the independent prognostic factors for overall survival.

RESULTS

MVV was significantly associated with gender (P < 0.001), age at diagnosis (P < 0.001), smoking history (P < 0.001), drinking history (P < 0.001), tumor length (P = 0.013), tumor location (P = 0.037) and treatment type (P = 0.001). The HALP score was notably associated with gender (P < 0.001), age at diagnosis (P = 0.035), tumor length (P < 0.001) and invasion depth (P = 0.001). Univariate Cox regression analysis showed that low MVV and low HALP score were associated with worse overall survival (all P < 0.001). Multivariate analysis showed that low MVV and the HALP score were both independent risk factors for overall survival (all P < 0.001). The combination of MVV and HALP score improved the prediction performance for overall survival than tumor-node-metastasis. Also, low combination of MVV and HALP score was an independent risk factor for poor overall survival (P < 0.001).

CONCLUSION

MVV, HALP score and their combination are simple and promising clinical markers to predict overall survival of ESCC patients.

Preoperative Low Vital Capacity Influences Survival After Esophagectomy for Patients with Esophageal Carcinoma

BACKGROUND

Assessment of preoperative physiological status is crucial for optimizing clinical outcomes in patients undergoing surgery for esophageal carcinoma (EC). We aimed to evaluate the prognostic impact of pulmonary dysfunctions and their relationships with other physiological factors, especially sarcopenia, in EC patients receiving esophagectomy.

METHODS

In total, 411 EC patients who underwent esophagectomy between 2006 and 2016 were retrospectively reviewed. Preoperative pulmonary functions were evaluated based on %vital capacity (%VC) and forced expiratory volume (FEV) 1.0%. The thresholds were set as the lowest quartile (99% for %VC and 68.6% for FEV1.0%) in this cohort.

RESULTS

One hundred and two patients (24.8%) had low %VC (%VC < 99%), which was significantly associated with age, comorbidity, sarcopenia and postoperative complications, while not correlating with pathological variables. The overall survival (OS) of patients in the low %VC group was significantly poorer than that of those in the high %VC group (P < 0.001), especially in those with pStage 0-II diseases (P < 0.001). In contrast, survival was not stratified by FEV1.0% (P = 0.80). Notably, patients with both low %VC and sarcopenia showed very poor 5-year OS (30.3%). Multivariate analysis revealed low %VC to be independently associated with poor OS (P = 0.03). In the cause-specific survival analyses, low %VC was an independent predictor of deaths from non-EC-related causes (P = 0.03).

CONCLUSIONS

Preoperative low %VC was independently associated with poor survival outcomes, especially when present in combination with sarcopenia, due to an increased risk of death from non-EC-related causes. Preoperative spirometry testing is useful for predicting long-term outcomes in EC patients undergoing esophagectomy.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study

OBJECTIVES

Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy.

DESIGN

Retrospective cohort study (level 3 evidence).

SETTING

Tertiary care referral center.

PARTICIPANTS

Patients who underwent esophagectomy from 2007 to 2017.

INTERVENTIONS

The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h).

MEASUREMENTS

Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use.

MAIN RESULTS

A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified.

CONCLUSIONS

Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Postoperative complications after minimally invasive esophagectomy in the prone position: any anesthesia-related factor?

OBJECTIVE

To evaluate the incidence of postoperative complications arising within 30 days of minimally invasive esophagectomy in the prone position with total lung ventilation and their relationship with 30-day and 1-year mortality. Secondary outcomes included possible anesthesia-related factors linked to the development of complications.

METHODS

The study is a retrospective single-center observational study at the Anesthesia and Surgical Department of a tertiary care center in the northeast of Italy. Patients underwent cancer resection through esophagectomy in the prone position without one-lung ventilation.

RESULTS

We included 110 patients from January 2010 to December 2017. A total of 54% of patients developed postoperative complications that increased mortality risk at 1 year of follow-up. Complications postponed first oral intake and delayed patient discharge to home. Positive intraoperative fluid balance was related to increased mortality and the risk to develop postoperative complications. C-reactive protein at third postoperative day may help detect complication onset.

CONCLUSIONS

Complication onset has a great impact on mortality after esophagectomy. Some anesthesia-related factors, mainly fluid balance, may be associated with postoperative mortality and morbidity. These factors should be carefully taken into account to obtain better outcomes after esophagectomy in the prone position without one-lung ventilation.

Esophageal cancer surgery: review of complications and their management

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

Major Postoperative Complications in Esophageal Cancer After Minimally Invasive Esophagectomy Compared With Open Esophagectomy: An Updated Meta-analysis

BACKGROUND

To evaluate the existing literature comparing cardiopulmonary complications after minimally invasive esophagectomy (MIE) with open esophagectomy (OE) and conduct a meta-analysis based on the relevant studies.

METHODS

A systematic search for articles was performed in Medline, Embase, Wiley Online Library, and the Cochrane Library. The relative risks or odds ratios (ORs) were calculated by using fixed or random-effects models. The I² and X² tests were used to test for statistical heterogeneity. We performed a metaregression for the pulmonary complications with the adenocarcinoma proportion and tumor stage. Publication bias and small-study effects were assessed using Egger's test and Begg's funnel plot.

RESULTS

A total of 30,850 participants were enrolled in the 63 studies evaluated in the meta-analysis. Arrhythmia, pulmonary embolism, pulmonary complications, gastric tip necrosis, anastomotic leakage, and vocal cord palsy were chosen as outcomes. The occurrence rate of arrhythmia was significantly lower in patients receiving MIE than in patients receiving OE (OR = 0.69; 95% CI = 0.53-0.89), with heterogeneity (I² = 30.7%, P = 0.067). The incidence of pulmonary complications was significantly lower in patients receiving MIE (OR = 0.54, 95% CI = 0.45-0.63) but heterogeneity remained (I² = 72.1%, P = 0.000). The risk of gastric tip necrosis (OR = 1.48, 95% CI = 1.07-2.05) after OE was lower than that after MIE. Anastomotic leakage, pulmonary embolism, and vocal cord palsy showed no significant differences between the two groups.

CONCLUSIONS

MIE has advantages over OE, especially in reducing the incidence of arrhythmia and pulmonary complications. Thus, MIE can be recommended as the preferred alternative surgery method for resectable esophageal cancer.

Precautions for avoiding pulmonary morbidity after esophagectomy

Pulmonary morbidity is the most common complication after esophagectomy. Importantly, it is the main cause of surgery-related mortality and possibly adversely affects the long-term outcome after surgery in patients with esophageal cancer. There is considerable accumulated evidence on multidisciplinary approaches to reduce post-operative pulmonary morbidity. A comprehensive review of the precautionary measures that have so far been shown to be effective in previous literature is of utmost importance. We herein update and summarize the perioperative and surgical approaches to diminish pulmonary morbidity. Pre-operative smoking cessation, respiratory rehabilitation, maintaining oral hygiene, perioperative nutritional intervention, enforcement of less invasive surgery, perioperative administration of steroid, and total management by a multidisciplinary team could be the key factors contributing to reduction in pulmonary morbidity.

Prognostic evaluation of esophageal cancer patients with stages I-III

PURPOSE

The purpose of this study was to investigate the impact of clinicopathological factors and treatments on the overall survival (OS) and esophageal cancer-specific survival (ECSS) of stages I-III esophageal cancer (EC) patients and to establish a prognostic visual nomogram.

METHODS

We collected clinical data of patients diagnosed with stages I-III EC without receiving chemotherapy from 2004 to 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. Prognoses were analyzed using the R language software, and nomograms were obtained according to the visual processing logistic regression model, which was verified using the Harrell C-index, receiver operating characteristic (ROC) curve, and calibration curve.

RESULTS

A total of 4,305 patients were selected, mostly white males. Most patients were over 60 years old and old age predicted poor prognosis. EC, primarily adenocarcinoma, occurred mostly in the lower third of the esophagus. About half of the patients had T1 (58.00%) and grade II (50.41%) cancer. Of all the patients, 2,448 was treated with surgery and the majority (n = 1,476; 64.85%) of these patients had stage I EC. Stages I-III patients underwent surgery had significantly better OS and ECSS, and endoscopic therapy was associated with the best outcome amongst all the surgical methods. 3.67% of the patients received radiotherapy, predominantly postoperative radiotherapy (2.69%). Older age, squamous cell carcinoma, overlapping lesion of the esophagus, and grades II and III were high-risk factors for poor OS and ECSS for stage I patients, whereas endoscopic therapy, esophagectomy, and esophagectomy with gastrectomy were low-risk factors. Stage II patients with older age, male sex, T3, N1, and grades II and III had shorter OS and ECSS, but patients with any surgical treatment had significantly longer OS and ECSS. T4, N1, and grade III correlated negatively with OS and ECSS in stage III patients, and any surgical treatment correlated positively with longer OS and ECSS. The OS and ECSS rates of stages I-III EC patients with a total score of more than 150 points in the nomogram were both only 40% after 3 years and 30% after 5 years. The C-index, ROC curve, and calibration curve indicated that the nomograms established in this study were suitable to assess patient prognosis.

CONCLUSION

The nomogram established in this study is an effective clinical tool to predict the prognosis of stages I-III EC patients without chemotherapy.

The effect of a pre- and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): Study protocol for a randomised controlled trial

BACKGROUND

Advances in peri-operative oncological treatment, surgery and peri-operative care have improved survival for patients with oesophagogastric cancers. Neoadjuvant cancer treatment (NCT) reduces physical fitness, which may reduce both compliance and tolerance of NCT as well as compromising post-operative outcomes. This is particularly detrimental in a patient group where malnutrition is common and surgery is demanding. The aim of this trial is to assess the effect on physical fitness and clinical outcomes of a comprehensive exercise training programme in patients undergoing NCT and surgical resection for oesophagogastric malignancies.

METHODS

The PERIOP-OG trial is a pragmatic, multi-centre, randomised controlled trial comparing a peri-operative exercise programme with standard care in patients with oesophagogastric cancers treated with NCT and surgery. The intervention group undergo a formal exercise training programme and the usual care group receive standard clinical care (no formal exercise advice). The training programme is initiated at cancer diagnosis, continued during NCT, between NCT and surgery, and resumes after surgery. All participants undergo assessments at baseline, post-NCT, pre-surgery and at 4 and 10 weeks after surgery. The primary endpoint is cardiorespiratory fitness measured by demonstration of a 15% difference in the 6-min walk test assessed at the pre-surgery timepoint. Secondary endpoints include measures of physical health (upper and lower body strength tests), body mass index, frailty, activity behaviour, psychological and health-related quality of life outcomes. Exploratory endpoints include a health economics analysis, assessment of clinical health by post-operative morbidity scores, hospital length of stay, nutritional status, immune and inflammatory markers, and response to NCT. Rates of NCT toxicity, tolerance and compliance will also be assessed.

DISCUSSION

The PERIOP-OG trial will determine whether, when compared to usual care, exercise training initiated at diagnosis and continued during NCT, between NCT and surgery and then during recovery, can maintain or improve cardiorespiratory fitness and other physical, psychological and clinical health outcomes. This trial will inform both the prescription of exercise regimes as well as the design of a larger prehabilitation and rehabilitation trial to investigate whether exercise in combination with nutritional and psychological interventions elicit greater benefits.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03807518 . Registered on 1 January 2019.

Predictive Factors of Acute Respiratory Failure in Esophagectomy for Esophageal Malignancy

Acute respiratory failure (ARespF) is a common complication after esophagectomy that contributes to higher morbidity and mortality. Using the Nationwide Inpatient Sample database, we sought to identify predictors of ARespF in 6352 patients who underwent esophagectomy for malignancy between 2006 and 2008. Multivariate regression analyses were performed to identify preoperative factors (patient characteristics, comorbidities, procedural type, tumor's location, hospital teaching status, and payer type) predictive of ARespF in esophagectomy. The overall rate of ARespF was 27.08 per cent. For comorbidities, independent risk factors for higher rate of ARF included weight loss (adjusted odds ratio [AOR], 3.63; 95% confidence interval [CI], 3.02 to 4.37), pulmonary hypertension (AOR, 2.38; 95% CI, 1.85 to 3.45), congestive heart failure (AOR, 2.35; 95% CI, 1.77 to 3.13), liver disease (AOR, 1.95; 95% CI, 1.22 to 3.12), chronic lung disease (AOR, 1.40; 95% CI, 1.17 to 1.66), and anemia (AOR, 1.26; 95% CI, 1.04 to 1.51). Cervical location of malignancy (AOR, 2.32; 95% CI, 1.51 to 3.56), total esophagectomy (AOR, 1.64; 95% CI, 1.41 to 1.90), and non-teaching hospital (AOR, 1.45; 95% CI, 1.20 to 1.75) were independent risk factors for ARespF. There was no effect of age, gender, race, hypertension, diabetes, renal failure, obesity, smoking, peripheral vascular disorder, or payer type on ARespF. We identified multiple preoperative risk factors that have an impact on development of ARespF after esophagectomy. Surgeons can use these factors to inform patients of potential risks and should consider these factors during surgical-decision making.

The Design of and Rationale for the Effect of Perioperative Inhaled Tiotropium for Patients with Chronic Obstructive Pulmonary Disease in Esophageal Cancer Surgery (EPITOPE): an Open-Label, Randomized, Parallel-Group Study

INTRODUCTION

Pneumonia is one of the most frequently occurring complications after esophagectomy and is associated with increased operative mortality. Chronic obstructive pulmonary disease (COPD) is known to be a risk factor for pulmonary complications and operative mortality. However, in COPD patients preparing for esophagectomy, preventive measures against postoperative pneumonia have not yet been discovered. In this study, we evaluate the effect of perioperative inhaled tiotropium, a long-acting, antimuscarinic bronchodilator used in the management of COPD, on patients with COPD who undergo esophageal cancer surgery.

METHODS/DESIGN

This study investigates the effect of perioperative inhaled tiotropium on patients with COPD who undergo esophagectomy. It is an open-label, randomized controlled trial conducted in a single center (EPITOPE study). A total of 32 enrolled patients are randomly assigned in a 1:1 ratio to either conventional management or inhalation of tiotropium in addition to the conventional management. Patients included in the intervention group receive tiotropium Respimat 5 μg (two inhalations of 2.5 μg) for at least 2 weeks before the esophagectomy. Following the esophagectomy, tiotropium is re-delivered, starting as early as possible and continuing until the postoperative evaluation (between 30 and 44 days after the operation). The primary outcome is the incidence of pneumonia within 30 days after esophagectomy. Secondary outcomes are the incidence of cardiovascular complications within 30 days after esophagectomy, the incidence of any postoperative complications within 30 days after esophagectomy, pulmonary function (preintervention, preoperative, and postoperative), walking distance in the incremental shuttle walking test (preintervention, preoperative, and postoperative), the incidence of adverse events, and mortality within 30 days after esophagectomy.

DISCUSSION

The EPITOPE study is the first pilot study on the effects of perioperative inhaled tiotropium on patients with COPD undergoing esophagectomy. After completing this study, we will plan a multicenter RCT with the appropriate outcomes in the future.

Preoperative six-minute walk distance as a predictor of postoperative complication in patients with esophageal cancer

Surgery for esophageal cancer is associated with high morbidity and mortality. Reduced pulmonary functions and exercise capacity are known as risk factors for complications after esophagectomy. The 6-minute walk distance (6MWD) measured by the 6-minute walk test (6MWT) is a simple field test that can be used to evaluate the functional exercise capacity of patients who undergo thoracic surgery. The aim of this study was to evaluate the association of the preoperative 6MWD with postoperative complications in patients with esophageal cancer. Records of a total of 111 patients who underwent thoracic surgery followed by postoperative rehabilitation from January 2013 to December 2015 were retrospectively reviewed. Data of patients who experienced Clavien-Dindo grade II or severer (grade ≥ II) complications were compared with those who experienced grade ≤I complications. The 6MWD was significantly correlated with age, serum albumin concentration, hemoglobin concentration, and hand grip strength. A total of 42 patients experienced grade ≥II. The 6MWD of patients with grade ≥ II complications was significantly shorter than that of those with grade ≤I complications. In receiver operating characteristic analysis, 6MWD ≤ 454 m was a threshold for predicting grade ≥II complications with 71.0% sensitivity and 54.8% specificity. The incidence of grade ≥II complications led to delayed ambulation and longer stays in hospital. In the multiple regression analysis, the preoperative risk factors for incidence of grade ≥II complications included lower levels of preoperative 6MWD and % of the predicted value of forced expiratory volume in 1 second. Our results indicate that the 6MWT is useful to assess preoperative physical status in patients with esophageal cancer.