Impact of the surgical technique on pulmonary morbidity after esophagectomy

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.

Understanding Post-Esophagectomy Complications and Their Management: The Early Complications

Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks.

Risk factors for postoperative infections in esophageal tumor patients

Postoperative infections (PI) are a serious complication after esophageal cancer surgery, as they might be correlated with an elevated risk of death. While several reports discuss risk factors for PI in esophageal tumor surgery, there is a limited amount of research on overall postoperative infections. Therefore, investigating the factors that influence PI holds great clinical significance. We retrospectively reviewed surgical data from a cohort of 902 patients diagnosed with esophageal tumors. The study included esophageal cancer patients treated in the Department of Thoracic Surgery at Anyang Tumor Hospital from January to December 2021. Preoperative and operative risk factors for PI were evaluated using univariable and multivariable analyses. The overall incidence of PI was 28.3% (255/902). Multivariable logistic regression analysis revealed that smoking and preoperative hospital stays are significant risk factors for PI after esophageal tumor surgery. Smoking and preoperative hospital stays are identified as risk factors for PI following esophageal tumor surgery. Based on our results, we predict that certain groups of patients may have a higher risk of PI following esophageal tumor surgery. Preventive measures or closely monitor of these patients may be required to reduce the incidence of postoperative PI.

Benefits of Prehabilitation before Complex Aortic Surgery

The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.

Association between preoperative diagnosis of sarcopenia and postoperative pneumonia in resectable esophageal squamous cell carcinoma patients: a retrospective cohort study

Background

Postoperative outcomes for patients suffering from resectable esophageal squamous cell carcinoma (ESCC) are related to sarcopenia. In patients with resectable ESCC, this study investigated the link between sarcopenia and postoperative pneumonia.

Methods

The McKewon procedure was the only one used to treat resectable ESCC patients from January 2018 to December 2021 in this retrospective analysis. Sarcopenia was assessed using skeletal muscles at L3 and planning CT scans. It was defined when PMI was below 6.36 cm²/m² and 3.92 cm²/m² for men and women, separately. Analyses of multivariate and univariate logistic regression were applied for identifying the risk factors for postoperative pneumonia.

Results

The study included 773 patients with resectable ESCC in total. Sarcopenia was an independent risk factor for postoperative pneumonia in individuals with resectable ESCC based on univariate and multivariate analysis (P < 0.05). The stratified analysis indicated that neither of the clinical outcomes in the logistic regression model were affected by gender, age, BMI, smoking, or pre-albumin (P for interaction > 0.006).

Conclusion

Following the McKewon procedure, patients with resectable ESCC who were sarcopenic had a higher postoperative pneumonia rate. To prevent the development of postoperative pneumonia during the perioperative period, it may be important to control the incidence of sarcopenia.

Robotic Belsey Mark IV Repair of the Paraesophageal Hernia

OBJECTIVE

Surgical repair of paraesophageal hernias in patients with hostile abdomen is challenging. Despite its utility as an open procedure, the adoption of the minimally invasive Belsey Mark IV procedure has been limited because of the complexity of using traditional video-assisted thoracoscopic instrumentation. The robotic platform offers additional degrees of freedom, which enables minimally invasive transthoracic approach despite challenging anatomy. The purpose of this article is to describe a technique of robotic approach for the Belsey Mark IV operation.

METHODS

We retrospectively reviewed 5 cases of the robotic Belsey Mark IV procedure completed at a single institution between June 2018 and November 2021. Data were collected from a review of the medical records, including operative reports, anesthesia records, imaging, and clinical notes. The operative technique is described in the present article. There were 4 men and 1 woman. The average age of the patients was 64.4 ± 13.6 years, with an average body mass index of 24.5 kg/m². Three patients had undergone previous transabdominal hiatal hernia repair, and 2 of them had 2 prior repairs. One patient underwent simultaneous pulmonary left lower lobectomy for cancer with the Belsey Mark IV procedure.

RESULTS

The average operative time was 209 ± 95 min (110 to 360 min). The average postoperative length of stay was 4.2 days, and 2 patients experienced complications including bleeding and persistent air leak (after lobectomy). The average blood loss was 67 ± 25 mL.

CONCLUSIONS

The robotic platform enables a transthoracic minimally invasive approach to the Belsey Mark IV operation.

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.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV_1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

Short-term outcome for high-risk patients after esophagectomy

Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.

Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases

BACKGROUND

Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE).

PATIENTS AND METHODS

Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups.

RESULTS

McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001).

CONCLUSION

McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.

Pilot Study of Patient Reported Outcomes in Patients with Esophageal Cancer following Esophagectomy

BACKGROUND

Patient-reported outcomes are critical measures of patient well-being following esophagectomy. In this pilot study, we assessed PROs before and after esophagectomy using the Patient Reported Outcomes Measurement Information System (PROMIS) to assess patient recovery following surgery.

METHODS

We prospectively collected PROMIS dyspnea severity, physical function, and pain interference measures from patients with esophageal cancer undergoing esophagectomy (2017-2020). We merged these data with our institutional Society of Thoracic Surgery esophagectomy database. We used linear mixed-effect multivariable models to assess changes in PROMIS scores (least square mean [LSM] differences) between pre-operative and post-operative timepoints (1-month, 6-month).

RESULTS

The study included 112 patients undergoing esophagectomy. Pain interference, physical function, and dyspnea severity scores were significantly worse 1 month following surgery. While physical function and dyspnea severity scores returned to baseline 6 months after surgery, pain interference scores remained persistently worse (LSM difference 2.7 ± 2.5, p=0.036). PROMIS scores were further assessed among patients undergoing transhiatal esophagectomy compared to transthoracic esophagectomy. Physical function and dyspnea severity scores were similar between the groups at each time point. However, pain interference scores were persistently better among patients undergoing THE at both 1 month (LSM difference 6.5 ± 5.1, p=0.013) and 6 months after surgery (LSM difference 5.2 ± 3.9, p=0.008).

CONCLUSIONS

This pilot study assessing PROMIS scores after esophagectomy for cancer reveals that pain is a persistently reported symptom up to 6 months following surgery, particularly among patients receiving transthoracic esophagectomy.

Perioperative Outcomes After Combined Esophagectomy and Lung Resection

INTRODUCTION

The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.

METHODS

Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.

RESULTS

Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).

CONCLUSIONS

Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

Clinical usefulness of sputum culture on the first postoperative day to predict early postoperative pneumonia after esophagectomy for esophageal cancer

BACKGROUND

Postoperative pneumonia is a serious prognostic problem that can appear after esophagectomy in patients with esophageal cancer. The past reports have considered the usefulness of perioperative culture examinations for predicting postoperative pneumonia; however, the direct relationship between these examinations and postoperative complications remains unclear.

METHODS

This study retrospectively analyzed esophageal cancer patients who underwent esophagectomy followed by sputum culture on the first postoperative day. The bacterial species that frequently cause hospital-acquired pneumonia were chosen as the target species in this study. The relationship between culture examination and postoperative pneumonia within one week (7 days) after esophagectomy was investigated.

RESULTS

Sputum cultures on the first postoperative day were investigated in 238 patients who underwent esophagectomy for esophageal cancer. Forty-one patients developed pneumonia within one week after surgery. The target bacterial species were detected in 26 of 238 sputum cultures (10.9%). In the univariate analysis, a Brinkman index, detection of target bacterial species, detection of Gram-positive cocci, and Gram-negative rods were significantly associated with postoperative pneumonia. In the three independent multivariate analyses, the target bacterial species, Gram-positive cocci, and Gram-negative rods (p = 0.001, 0.042, and < 0.001) were individually identified as independent risk factors of postoperative pneumonia in addition to a Brinkman index.

CONCLUSIONS

Detection of target bacterial species by sputum culture on the first postoperative day after esophagectomy was an independent risk factor of postoperative pneumonia within 7 days after surgery. Prospective studies for the prevention of early postoperative pneumonia using sputum culture on the first postoperative day can be considered.

Management of Postoperative Complications After Esophageal Resection

Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.

Minimally Invasive Versus Open McKeown for Patients with Esophageal Cancer: A Retrospective Study

INTRODUCTION

McKeown minimally invasive esophagectomy (McKeown-MIE) offers advantages in short-term outcomes compared with McKeown open esophagectomy (McKeown-OE); however, debate as to whether MIE is equivalent or better than OE regarding survival outcomes is ongoing.

OBJECTIVE

The aim of this study was to compare long-term survival between McKeown-MIE and McKeown-OE in a large cohort of esophageal cancer (EC) patients.

METHODS

We used a prospective database (independently managed by LinkDoc company) of the Thoracic Surgery Department at Henan Cancer Hospital and included patients who underwent McKeown-MIE and McKeown-OE for EC from 1 January 2015 to 6 January 2018. The perioperative data and overall survival (OS) rate in the two groups were retrospectively compared.

RESULTS

We included 502 patients who underwent McKeown-MIE (n = 306) or McKeown-OE (n = 196) for EC. The median age in the total patient population was 63 years. All baseline characteristics were well-balanced between the two groups. There was a significantly shorter mean operative time (269.76 min vs. 321.14 min, p < 0.001) in the OE group. The 30-day and in-hospital mortality rates were 0, and there was no difference in 90-day mortality (p = 0.053) between the groups. The postoperative stay was shorter in the MIE group and was 14 days and 18 days in the MIE and OE groups, respectively (p < 0.001). The OS at 60 months was 58.8% and 41.6% in the MIE and OE groups, respectively (p < 0.001) [hazard ratio 1.783, 95% confidence interval 1.347-2.359].

CONCLUSIONS

These results showed that McKeown-MIE was associated with better long-term survival than McKeown-OE for patients with resectable EC.

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.

Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis

BACKGROUND

Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer.

METHODS

A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed.

RESULTS

Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery.

CONCLUSION

Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

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.

Prevention of postoperative pneumonia by perioperative oral care in patients with esophageal cancer undergoing surgery: a multicenter retrospective study of 775 patients

PURPOSE

Postoperative pneumonia is one of the major complications after esophageal cancer surgery. The risk factors associated with postoperative pneumonia are poor general health, smoking, decreased pulmonary function, diabetes mellitus, surgical stress, old age, postoperative aspiration, and oral hygiene. In this study, we examined the effect of perioperative oral care on reducing postoperative pneumonia since the evidence to-date is not clear.

METHODS

A multicenter, retrospective investigation of the relationship between perioperative oral care and incidence of postoperative pneumonia in patients undergoing esophageal cancer surgery was conducted. A total of 775 patients who underwent thoracoscopic esophageal resection at 25 hospitals between 2016 and 2017 were enrolled in the study. Various factors were examined for correlation with development of postoperative pneumonia.

RESULTS

Multivariate analysis showed that old age, smoking habit, lower hemoglobin, higher creatinine, postoperative dysphagia, and lack of oral care intervention were independent risk factors for pneumonia. Oral care was more effective in preventing pneumonia in hospitals in which the incidence of postoperative pneumonia was lower than 20%, while it was not effective in hospitals in which the incidence was higher than 20%.

CONCLUSION

Results of the study suggest that it is recommended to carry out perioperative oral care in esophageal cancer surgery.

Surgical Anatomy of Paraesophageal Hernias

Paraesophageal hernia represents a complex surgical problem involving significant distortion of the anatomy and function of the esophagus, stomach, gastroesophageal junction, mediastinum, lungs, and heart. Surgeons operating in the area must have deep understanding of the normal anatomy and pathologic derangements in patients with paraesophageal hernias. This article describes the normal anatomy and anatomic abnormalities in application to the various approaches used in the surgical repair of a paraesophageal hernia.

Innovative and Contemporary Interventional Therapies for Esophageal Diseases

Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with "end-stage" esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.

Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option

Modern esophagectomy includes the esophageal extirpation with immediate reconstruction of the gastrointestinal (GI) continuity via posterior mediastinal route. In the majority of cases tubularized stomach is chosen as the conduit of choice. Other conduits, such as colon or small bowel can be used for these purposes as well. In rare circumstances use of the alternative route for the conduit placement is required. Authors describe the technique of robotic substernal esophageal bypass and reconstruction of the esophageal continuity.

Minimally Invasive and Robotic Esophagectomy: A Review

Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.

Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the first clinical series

BACKGROUND

Radical esophagectomy for esophageal cancer is associated with high morbidity, especially with pulmonary complications. Mediastinoscopic esophagectomy via a small left neck incision combined with the esophageal hiatus, without using transthoracic approach, has been reported to reduce pulmonary complication; however, from technical point of view, this approach using non-articulating, straight, long forceps is extremely challenging, especially in the middle mediastinal area. Its technical difficulties may be attenuated using da Vinci Surgical System. The aim of this study was to evaluate the feasibility and safety of robot-assisted mediastinoscopic esophagectomy.

METHODS

Robot-assisted mediastinoscopic esophagectomy was performed in six patients between October 2016 and May 2017. Robotic esophageal mobilization with upper and middle mediastinal lymphadenectomy was performed via the three da Vinci Xi (Intuitive Surgical, Inc. Sunnyvale, CA) trocars placed on the 5-cm left cervical incision. Thereafter, the remaining part of radical esophagectomy was completed via a transhiatal approach.

RESULTS

Upper and middle mediastinal lymphadenectomy was robotically completed via the transcervical approach in all cases without conversion to transthoracic approach. No postoperative complications (Clavien-Dindo classification grade ≥ III) were observed.

CONCLUSIONS

Robot-assisted mediastinoscopic esophagectomy was technically feasible and safe. Use of da Vinci Surgical System may help attenuate technical difficulties in transcervical middle mediastinal lymph node dissection.

Long-term pharyngeal dysphagia after esophagectomy for esophageal cancer-an investigation using videofluoroscopic swallow studies

Dysphagia is a common symptom of esophageal cancer (EC). Esophagectomy should relieve the presenting dysphagia as the mechanical obstruction caused by the tumor is removed. However, the new onset oropharyngeal dysphagia develops after esophagectomy and the deficit may persist increasing the risk of aspiration pneumonia and mortality as well as adversely affecting quality of life (QOL). This study investigates the persistent swallowing deficits in long-term postesophagectomy patients and explores the factors associated with dysphagia severity, penetration, and aspiration. A better understanding of the swallowing function can aid future management of the condition. A total of 29 patients who were more than six months postesophagectomy for EC, had no history of disease that would likely affect swallowing function or vocal cord palsy underwent detailed videofluoroscopic swallow studies and completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and OES18 QOL questionnaires. Swallowing deficits were analyzed and rated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). These variables were correlated with the clinical and QOL parameters to determine which factors would affect swallowing function. Our cohort consisted of 27 males and 2 females. The mean duration after esophagectomy when the swallowing study was performed was 3.2 years (range: 0.5-18.4 years). Swallowing deficits were mainly found in the pharyngeal phase of swallowing. The mean total VDS score was 36.1 (SD = 15.2, range: 11.0-69.5) out of a possible 100. The mean PAS score was 4.1 (SD = 2.5, range: 1-8) and 1.5 (SD = 0.9, range: 1-4) for thin and semisolids, respectively. Dysphagia was significantly more severe in males, those of more advanced age at esophagectomy and at swallowing assessment. Increasing pathological N stage significantly correlated with worse PAS score for thin fluid. Self-reports of more pain and less troubles with coughing were also associated with less penetration and aspiration. This study demonstrated that a mild to moderate pharyngeal dysphagia is present late after esophagectomy even in patients without VC palsy or anastomotic stricture. The long-term aspiration rate is comparable to the figures in the literature for those early after esophagectomy. It is suggested that damage to the intercostal nerves and the pulmonary vagus may affect oropharyngeal swallowing function in this population.

Clinical usefulness of a perioperative bacteriological culture to treat patients with postoperative pneumonia after esophagectomy

AIM

The aim of the present study was to examine the usefulness of a perioperative bacteriological culture in predicting the pathogenic bacteria responsible for postoperative pneumonia after esophagectomy.

METHODS

This study included 293 consecutive esophageal cancer patients who underwent esophagectomy with gastric conduit reconstruction. We compared the pathological bacteria that were detected in bacteriological cultures of sputum, mouthwash and gastric fluid on the second postoperative day with the pathogenic bacteria responsible for postoperative pneumonia.

RESULTS

Postoperative pneumonia occurred in 26 (8.8%) of the 293 patients. Enterobacter cloacae was detected most frequently in the perioperative bacteriological culture, followed by Enterococcus faecalis and Pseudomonas aeruginosa. Detection of each pathogenic bacterium in the perioperative bacteriological culture was not associated with the occurrence of pneumonia, excluding Pseudomonas aeruginosa. As the pathogens responsible for postoperative pneumonia, 32 bacteria were detected in 26 patients with postoperative pneumonia. Detection rate of the pathogenic bacteria responsible for postoperative pneumonia in a perioperative bacteriological culture was 43.8% in a sputum culture, 40.6% in a mouthwash culture and 65.6% in a gastric fluid culture. The detection rate of the pathogenic bacteria responsible for pneumonia was up to 78.1% in the combination of sputum and gastric fluid culture.

CONCLUSIONS

Although the perioperative bacteriological culture does not seem to be useful for predicting the occurrence of postoperative pneumonia, it is useful for predicting the pathogenic bacteria responsible for pneumonia in cases of postoperative pneumonia. The perioperative bacteriological culture helps us to select appropriate antibiotics to treat pneumonia after esophagectomy.

Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy for esophageal squamous cell carcinoma: a case series

Objective:

Minimally invasive esophagectomy (MIE) is increasingly used for the treatment of esophageal cancer. However, MIE via the Sweet approach has seldom been reported owing to the challenging procedure for a mediastinal lymph node. Thus, the approach of MIE via left-sided thoracoscopy coupled with video-assisted cervical mediastinoscopy (MIE-SM) was explored for eradicating the mediastinal lymph nodes and recurrent laryngeal nerve; the incidence of perioperative complications, mortality, and surgical radicality were analyzed.

Materials and Methods:

Thirty patients with esophageal carcinoma underwent MIE-SM between June 2014 and February 2016. The primary outcome was postoperative morbidity within 2 weeks postsurgery. The secondary outcome was surgical radicality, including the circumferential margins, and the number of lymph nodes dissected.

Results:

The MIE-SM was completed in all patients within 367.6±68.7 minutes. The incidences of postoperative morbidities including pulmonary complications, anastomotic leakage, chylothorax, or recurrent nerve injury were 43.3%.

Conclusion:

The MIE-SM was utilized for the first time to reduce the disadvantage of purely Sweet and McKeown approach, with favorable efficacy in the mediastinal and laryngeal recurrent nerve lymph node eradication. Thus, MIE-SM might be a promising alternative approach in treating esophageal cancer in selected patients.

Spirometric Lung Age Predicts Postoperative Pneumonia After Esophagectomy

BACKGROUND

Despite advances in treatment, postoperative pneumonia remains a major problem after esophagectomy. Lung age has been proposed as a comprehensive indicator for respiratory function. The aim of this study is to reveal the efficacy of lung age in predicting occurrence of pneumonia after esophagectomy.

METHODS

We assessed 342 consecutive patients who underwent subtotal esophagectomy for primary esophageal cancer from 2011 to 2014. Lung age was calculated from the preoperative spirometric test using the methods advocated by the Japanese Respiratory Society. We investigated factors predicting the occurrence of postoperative pneumonia after esophagectomy.

RESULTS

The incidence of postoperative pneumonia was 28.9 %. According to the Clavien-Dindo classification, grade II and grade III-V pneumonia were observed in 21.3 and 7.6 % patients, respectively. In multivariate logistic regression analysis for the factors predicting the occurrence of postoperative pneumonia, higher lung age (p = 0.010) and lower body mass index (p = 0.006) were independent factors. Patients with grade III-V pneumonia tended to have higher lung age than those with grade II pneumonia (p = 0.084). In addition, lung age was significantly higher in patients who experienced pneumonia within postoperative days 7 than those who experienced pneumonia after postoperative days 7 (p = 0.028).

CONCLUSION

Spirometric lung age was associated with occurrence, severity, and time of onset of postoperative pneumonia after esophagectomy. This simple parameter deserves a greater consideration as a predictor of postoperative pneumonia after esophagectomy and can support both surgeons and patients in understanding the status of respiratory function.

Clinical outcomes of video-assisted thoracoscopic surgery esophagectomy for esophageal cancer: a propensity score-matched analysis

Background

Minimally invasive esophagectomy theoretically offers advantages compared with open esophagectomy (OE). The aim of this study was to compare the early- and mid-term outcomes between video-assisted thoracoscopic surgery (VATS) esophagectomy (VE) and OE in patients with esophageal cancer.

Methods

Between November 2011 and July 2015, a total of 172 patients were divided into two groups depending on the method of esophagectomy: the VE group (n=42) and the OE group (n=130). A propensity analysis that incorporated perioperative variables, such as age, sex, preoperative pulmonary function, Charlson comorbidity index, tumor location, histologic grade of the tumor, pathologic stage and operative procedure (Ivor Lewis or McKeown) was performed, and postoperative outcomes were compared.

Results

Matching based on propensity scores produced 42 patients in each group for the analysis. After propensity matching, there were only two operative mortalities in the OE group, and both died of postoperative pneumonia. The overall incidence of postoperative complications was 38.1% (16 of 42) and 57.1% (24 of 42) in the VE group and in the OE group, respectively (P=0.088). The incidence of pulmonary complications was lower in the VE group than in the OE group (9.5% vs. 40.5%, P=0.004). The 2-year overall survival and disease-free survival were not different between the two groups (74.4% and 69.5% in the VE group, 69.5% and 69.8% in the OE group, P=0.865 and P=0.513, respectively).

Conclusions

In select patients, superior short-term surgical results and equal oncological outcomes were achieved with VE compared with OE.

Effect of perioperative oral care on prevention of postoperative pneumonia associated with esophageal cancer surgery: A multicenter case-control study with propensity score matching analysis

The aim of this study was to investigate the effectiveness of oral care in prevention of postoperative pneumonia associated with esophageal cancer surgery.Postoperative pneumonia is a severe adverse event associated with esophageal cancer surgery. It is thought to be caused by aspiration of oropharyngeal fluid containing pathogens. However, the relationship between oral health status and postoperative pneumonia has not been well investigated.This study included 539 patients with esophageal cancer undergoing surgery at 1 of 7 university hospitals. While 306 patients received perioperative oral care, 233 did not. Various clinical factors as well as occurrence of postoperative pneumonia were retrospectively evaluated. Propensity-score matching was performed to minimize selection biases associated with comparison of retrospective data between the oral care and control groups. Factors related to postoperative pneumonia were analyzed by logistic regression analysis.Of the original 539 patients, 103 (19.1%) experienced postoperative pneumonia. The results of multivariate analysis of the 420 propensity score-matched patients revealed longer operation time, postoperative dysphagia, and lack of oral care intervention to be significantly correlated with postoperative pneumonia.The present findings demonstrate that perioperative oral care can reduce the risk of postoperative pneumonia in patients undergoing esophageal cancer surgery.

Minimally Invasive Ivor-Lewis Esophagectomy (MIILE): A Single-Center Experience

With the development of minimally invasive procedures, minimally invasive Ivor-Lewis esophagectomy (MIILE) has been proposed as a safe and feasible surgical choice for the treatment of esophageal cancer. This retrospective study evaluated MIILE results from a single medical center. A total of 619 patients were selected as candidates for Ivor-Lewis esophagectomy from December 2011 to May 2015, in which 334 patients accepted MIILE and 285 patients accepted open Ivor-Lewis esophagectomy (OILE). General characteristics, surgical data, complication rates, and survival were analyzed. Differences in general characteristics between groups were not significant. Intraoperative blood loss (P < 0.01), postoperative volume of drainage for the first day (P < 0.01), time to drain removal (P ≤ 0.01), wound infection rate (P = 0.04), and length of hospital stay (P < 0.01) were significantly reduced in the MIILE group. There were no statistically significant differences in general morbidity (P = 0.56), the total swept lymph nodes (P = 0.47), mortality (P = 0.34), and survival rate at 3 years (P = 0.63). MIILE is a safe and feasible method for the treatment of esophageal cancer, in which good outcomes were reported and some advantages were found over the open procedure.

Short-term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery

Transthoracic esophagectomy (TTE) is believed to have advantages for mediastinal lymphadenectomy in the treatment of resectable esophageal cancer despite its association with a greater incidence of pulmonary complications and postoperative mortality. Transhiatal esophagectomy is regarded as less invasive, though insufficient in terms of lymph node dissection. With the aim of achieving lymph dissection equivalent to that of TTE, we have developed a nontransthoracic esophagectomy (NTTE) procedure combining a video-assisted cervical approach for the upper mediastinum and a robot-assisted transhiatal approach for the middle and lower mediastinum. We prospectively studied 22 accumulated cases of NTTE and verified feasibility by analyzing perioperative and histopathological outcomes. We compared this group's short-term outcomes with outcomes of 139 equivalent esophageal cancer cases operated on at our institution by conventional TTE (TTE group). In the NTTE group, there were no procedure-related events and no midway conversions to the conventional surgery; the mean operation time was longer (median, 524 vs. 428 minutes); estimated blood loss did not differ significantly between the two groups (median, 385 mL vs. 490 mL); in the NTTE group, the postoperative hospital stay was shorter (median, 18 days vs. 24 days). No postoperative pneumonia occurred in the NTTE group. The frequencies of other major postoperative complications did not differ significantly, nor were there differences in the numbers of harvested mediastinal lymph nodes (median, 30 vs. 29) or in other histopathology findings. NTTE offers a new radical procedure for resection of esophageal cancer combining a cervical video-assisted approach and a transhiatal robotic approach. Although further accumulation of surgical cases is needed to corroborate these results, NTTE promises better prevention of pulmonary complications in the management of esophageal cancer.

Preventive Effect on Post-Operative Pneumonia of Oral Health Care among Patients Who Undergo Esophageal Resection: A Multi-Center Retrospective Study

BACKGROUND

Post-operative pneumonia is a frequent and possibly fatal complication of esophagectomy and is likely caused by aspiration of oropharyngeal fluid that contains pathogenic micro-organisms. We conducted a multi-center retrospective study to investigate the preventive effect of oral health care on post-operative pneumonia among patients with esophageal cancer who underwent esophagectomy.

METHODS

A total of 280 patients underwent esophagectomy at three university hospitals. These patients were divided retrospectively into those who received pre-operative oral care from dentists and dental hygienists (oral care group; n = 173) and those who did not receive such care (control group; n = 107). We evaluated the correlations between the occurrence of post-operative pneumonia and 18 predictive variables (patient factors, tumor factors, treatment factors, and pre-operative oral care) using the χ(2) test and logistic regression analysis. The differences of mean hospital days and mortality rate in both groups were analyzed by the Student t-test.

RESULTS

Age, post-operative dysphagia, and absence of pre-operative oral care were correlated significantly with post-operative pneumonia in the univariable analysis. Multivariable analysis revealed that diabetes mellitus, post-operative dysphagia, and the absence of pre-operative oral care were independent risk factors for post-operative pneumonia. The mean hospital stay and mortality rate did not differ between the oral care and control groups.

CONCLUSION

Pre-operative oral care may be an effective and easy method to prevent post-operative pneumonia in patients who are undergoing esophagectomy.

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.

Construct validation: simulation of thoracoscopic intrathoracic anastomosis

BACKGROUND AND OBJECTIVES

We sought to develop a simulation model that accurately replicates the challenges of the thoracoscopic intrathoracic anastomosis. This model is intended to serve as a teaching tool during the introduction to, and development of, the skills required to perform a thoracoscopic intrathoracic anastomosis during an Ivor Lewis minimally invasive esophagectomy.

METHODS

The simulation model uses porcine tissue placed within an artificial hemithorax and covered with a synthetic skin. The model is draped to simulate a realistic operative setting, and ports are placed in standard surgical fashion. Dissection of the esophagus from the mediastinum is then performed, followed by the creation of an esophagogastric anastomosis. The effectiveness of the training model was evaluated using volunteer general and thoracic surgery residents at varying stages of surgical training. The quality of the anastomoses created were evaluated using both objective and subjective criteria, and successful anastomoses were tested for leaks using hydrostatic pressure.

RESULTS

Objective evaluation showed that successful completion of the anastomosis task increased with the number of attempts, with 100% of participants successfully completing an anastomosis by the final attempt. The time to completion of a successful anastomosis also improved across successive attempts. Moreover, objective measures also showed improvement over time based on the graded quality of the completed anastomosis.

CONCLUSION

As surgical techniques continue to evolve, so must the means by which they are taught. This simulation model shows effectiveness in the training of general and thoracic surgery residents performing thoracoscopic intrathoracic anastomosis during the Ivor Lewis minimally invasive esophagectomy.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does minimally invasive oesophagectomy provide a benefit in hospital length of stay when compared with open oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?' A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.

Original scoring system for predicting postoperative morbidity after esophagectomy for esophageal cancer

PURPOSE

Postoperative morbidity remains common after esophagectomy. There are currently few tools that can be used to estimate the incidence of complications. This study aimed to create a novel scoring system for predicting postoperative morbidity.

METHODS

A total of 365 patients who underwent elective esophagectomy with two- or three-field lymphadenectomy for esophageal cancer were retrospectively analyzed. Patients were divided into development (n = 250) and validation datasets (n = 115). A scoring system was established by specifying the expected morbidity incidence values for all independent predictors in the development dataset, after which, the reproducibility was confirmed in the validation dataset.

RESULTS

The incidence of any morbidity was 44.7 %. Male sex, severe emaciation (body mass index <18), a lower performance status (grade 1 or 2), operation ≥540 min and massive bleeding (blood loss/body weight ≥20) were independent predictors of postoperative morbidity. The total of all predictive scores was calculated. The incidence of any morbidity and of severe morbidity (Clavien-Dindo classification ≥IIIb) significantly correlated with the score after dividing the scores into three groups (≤8, 10 and 11 and ≥13). This finding was also confirmed in the validation dataset.

CONCLUSION

The current scoring system is considered to be useful for predicting postoperative morbidity after esophagectomy.

Surgical indications and optimization of patients for resectable esophageal malignancies

Esophageal cancer is a devastating diagnosis with very dire long-term survival rates. This is largely due to its rather insidious progression, which leads to most patients being diagnosed with advanced disease. Recently, however, a greater understanding of the pathogenesis of esophageal malignancies has afforded surgeons and oncologists with new opportunities for intervention and management. Coupled with improvements in imaging, staging, and medical therapies, surgeons have continued to enhance their knowledge of the nuances of esophageal resection, which has resulted in the development of minimally invasive approaches with similar overall oncologic outcomes. This marriage of more efficacious induction therapy and diminished morbidity after esophagectomy offers new promise to patients diagnosed with this aggressive form of cancer. The following review will highlight these most recent advances and will offer insight into our own approach to patients with resectable esophageal malignancy.