Does previous fundoplication alter the surgical approach to esophageal adenocarcinoma?

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

Endoscopic mucosal or submucosal resection of early neoplasia in Barrett's esophagus after antireflux surgery

BACKGROUND

Endoscopic resection and radiofrequency ablation are now established therapies for high-grade intraepithelial neoplasia and mucosal cancer complicating Barrett's esophagus. These techniques may be more challenging in patients with previous antireflux surgery, because of poor visibility and accessibility.

OBJECTIVE

To assess the results of endoscopic resection for early neoplasia complicating Barrett's esophagus after antireflux surgery.

DESIGN

Case series, retrospective review.

SETTING

Single tertiary-care referral center.

PATIENTS

This study involved 7 patients treated for Barrett's neoplasia by endoscopic resection between 2001 and 2009.

INTERVENTIONS

Endoscopic resection was performed by using the EMR cap technique or by endoscopic submucosal dissection.

MAIN OUTCOME MEASUREMENTS

The curative resection rate, complications, follow-up, and complete remission status were determined.

RESULTS

Seven patients underwent endoscopic resection (mean number of sessions, 3.1; range, 1-6): endoscopic submucosal dissection in 3 patients and EMR in 4 patients. Two patients needed additional argon plasma coagulation. Pathology examination disclosed invasive adenocarcinoma in 3 patients and high-grade intraepithelial neoplasia in 4 patients. At the last follow-up examination, all patients were in complete remission. Major procedure-related complications were not encountered.

LIMITATIONS

Small number of patients, single center, retrospective study.

CONCLUSIONS

We demonstrated that full endoscopic resection by using EMR or endoscopic submucosal dissection in patients with previous antireflux surgery can be achieved successfully and safely. These patients can be treated endoscopically, similarly to patients without previous surgery.

Esophagectomy after anti-reflux surgery

OBJECTIVE

There are few data on whether prior fundoplication has an impact on subsequent esophageal resection and reconstruction. The aim of this study is to review our experience with patients undergoing esophagectomy after previous fundoplication.

METHODS

Medical records were reviewed of all patients undergoing esophageal resection from 1988 to 2008 at the Mayo Clinic. Patients with a fundoplication before esophagectomy were compared with a matched control group who had esophagectomy alone.

RESULTS

There were 2313 esophageal resections, and 80 patients had undergone at least 1 previous anti-reflux surgery. Indications for esophagectomy were benign stricture/perforation in 41 patients, cancer in 28 patients, and dysplasia in 11 patients. The surgical approach was Ivor Lewis in 38 patients, left thoracoabdominal in 29 patients, transhiatal in 10 patients, and McKeown in 3 patients. The conduit used was stomach in 70 patients, jejunum in 6 patients, and colon in 3 patients; 1 patient had a diversion and cervical esophagostomy only. Operative mortality occurred in 3 patients (3.7%). Postoperative complications occurred in 50 patients (62.5%), including anastomotic leak in 17 (21.5%). Sixteen patients (20%) required reoperation for complications. Complication, anastomotic leak, and reoperation rates were significantly higher in patients with anti-reflux surgery before esophagectomy compared with matched controls.

CONCLUSION

Esophagectomy after prior anti-reflux surgery is challenging, but the stomach is usually a suitable conduit for esophageal replacement. Patients with a history of anti-reflux surgery who undergo esophagectomy are at significantly increased risk for postoperative complications, anastomotic leak, and need for reoperation.

Prognostic value of p53 mutations in oesophageal adenocarcinoma: final results of a 15-year prospective study

OBJECTIVE

This study evaluates the clinical significance of p53 mutations in oesophageal adenocarcinoma (EADC).

METHODS

Between February 1991 and February 2006, 142 consecutive patients with EADC underwent potentially curative oesophageal resection. No patient received induction therapy. Strict clinicopathologic criteria were used to define primary EADC (Type I), excluding gastric cardia adenocarcinoma (Type II). Genomic DNA was extracted from oesophageal tumours, each with matched histologically normal oesophageal epithelium (internal control) from the resection margin. Polymerase chain reaction was used to amplify p53 exons 4-10, and mutations were characterised by direct DNA sequencing. The p53 mutations were correlated with clinicopathologic findings, p53 protein expression determined using immunohistochemistry, and outcome using Kaplan-Meier and Cox proportional hazards models.

RESULTS

For all patients, 5-year overall survival (OS) was 26.9%. Conventional predictors of reduced OS included advanced pathological tumour-node-metastasis (pTNM) stage (P<0.0001) and number of involved lymph nodes (0, 1-3, >3; P<0.0001). No p53 mutations were found in normal oesophageal epithelia. A total of 47% of tumours (67/142) had p53 mutations, predominantly G:C to A:T transitions at CpG dinucleotides (36/67). The p53 mutations were associated with p53 protein overexpression (P<0.0001) and poor tumour differentiation (P=0.037). Patients whose tumours had p53 mutations had significantly reduced 5-year OS (hazard ratio (HR): 1.54; 95% confidence interval (CI): 1.03-2.3; P=0.03).

CONCLUSIONS

Patterns of p53 mutations in EADC suggest endogenous molecular mechanisms. The p53 mutations are a predictor of significantly reduced postoperative survival following surgical resection of EADC, and would appear to be a clinically useful molecular prognostic biomarker.