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Qi WX, Li S, Li H, Chen J, Zhao S. The addition of pembrolizumab to neoadjuvant chemoradiotherapy did not increase the risk of developing postoperative anastomotic leakage for ESCC: an analysis from a prospective cohort. BMC Cancer 2024; 24:1029. [PMID: 39164624 PMCID: PMC11337814 DOI: 10.1186/s12885-024-12774-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 08/06/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND To compare the difference of postoperative anastomotic leakage (AL) rate between neoadjuvant chemoradiotherapy (NCRT) with pembrolizumab and NCRT group, and investigate the risk factors of developing AL for locally advanced esophageal squamous cell cancer (ESCC). MATERIALS AND METHODS The GF was contoured on the pretreatment planning computed tomography and dosimetric parameters were retrospectively calculated. Univariate and multivariate logistic regression analysis was performed to determine the independent risk predictors for the entire cohort. A nomogram risk prediction model for postoperative AL was established. RESULTS A total of 160 ESCC patients were included for analysis. Of them, 112 were treated with NCRT with pembrolizumab and 44 patients with NCRT. Seventeen (10.6%) patients experienced postoperative AL with a rate of 10.7% (12/112) in NCRT with pembrolizumab and 11.4% (5/44) in NCRT group. For the entire cohort, mean, D50, Dmax, V5, V10 and V20 GF dose were statistically higher in those with AL (all p < 0.05). Multivariate logistic regression analysis indicated that tumor length (p = 0.012), volume of GF (p = 0.003) and mean dose of GF (p = 0.007) were independently predictors for postoperative AL. Using receiver operating characteristics analysis, the mean dose limit on the GF was defined as 14 Gy. CONCLUSION Based on our prospective database, no significant difference of developing AL were observed between NCRT with pembrolizumab and NCRT group. We established an individualized nomograms based on mean GF dose combined with clinical indicators to predict AL in the early postoperative period.
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Affiliation(s)
- Wei-Xiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Proton-therapy, Shanghai, 201801, China
| | - Shuyan Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Proton-therapy, Shanghai, 201801, China
| | - Huan Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Proton-therapy, Shanghai, 201801, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Proton-therapy, Shanghai, 201801, China.
| | - Shengguang Zhao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Proton-therapy, Shanghai, 201801, China.
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2
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Hijab A, Tova Y, Alani S. The Right Gastroepiploic Artery as a Potential Organ at Risk in Neoadjuvant Chemoradiation for Esophageal and Gastroesophageal Cancers. Cureus 2024; 16:e61342. [PMID: 38947627 PMCID: PMC11214067 DOI: 10.7759/cureus.61342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Preoperative chemoradiation is a standard of care for esophageal and gastroesophageal cancer. A gastric conduit is usually used for anastomosis with the right gastroepiploic artery (RGEA) being the sole arterial supply to the gastric remnant after such surgeries. Hence, lowering the radiation dose to this vessel may lower the risks of postoperative complications related to poor vasculature. Herein, we report our experience in contouring and replanning cases of distal esophageal/gastroesophageal carcinomas so that the radiation doses to the RGEA could be minimized. MATERIALS AND METHODS Radiation plans of patients with lower esophageal/gastroesophageal carcinomas were retrieved from our database. Identification and delineation of the RGEA was done and replanning was performed with the aim to keep the maximal and mean doses as well as the V10Gy and V20Gy of the RGEA as low as possible without compromising target volume coverage. Results: We achieved significant dose reductions in most of the dosimteric parameters in our selected cases without compromising target coverage. CONCLUSION Lowering the dose to the RGEA, a potential organ-at-risk that may impact the postoperative course after neoadjuvant chemoradiation, is feasible.
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Affiliation(s)
- Adham Hijab
- Radiotherapy, Ziv Medical Centre, Safad, ISR
| | - Yonina Tova
- Radiotherapy, Ziv Medical Centre, Safad, ISR
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3
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Seo HW, Jeon YJ, Cho JH, Kim HK, Choi YS, Zo JI, Shim YM. Treatment Patterns and Outcomes of Anastomotic Leakage after Esophagectomy for Esophageal Cancer. J Chest Surg 2024; 57:152-159. [PMID: 38228498 DOI: 10.5090/jcs.23.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/22/2023] [Accepted: 11/21/2023] [Indexed: 01/18/2024] Open
Abstract
Background Anastomotic leakage (AL) following esophagectomy represents a serious complication that often results in prolonged hospitalization and necessitates repeated interventions, including nothing-by-mouth (NPO) restriction, endoscopic vacuum therapy (EVT), or surgical repair. In this study, we evaluated the patterns and outcomes of AL treatment. Methods We retrospectively reviewed the medical records of patients who underwent esophagectomy for esophageal cancer at a single center between 2003 and 2020. Of 3,096 examined cases, 181 patients (5.8%) with AL were included in the study: 114 patients (63%) with cervical anastomosis (CA) and 67 (37%) with intrathoracic anastomosis (TA). Results The incidence of AL was 11.9% in the CA and 3.2% in the TA group (p<0.001). Among patients with CA who developed AL, 87 (76.3%) were managed with NPO, 15 (13.2%) with EVT, and 12 (10.5%) with surgical repair. Over 90% of patients with cervical AL resumed an oral diet by the time of discharge, regardless of treatment method. Among patients with TA and AL, 36 (53.7%) received NPO, 25 (37.7%) underwent EVT, and 6 (9%) required surgery. Of these, 34 patients who were managed with NPO and 19 with EVT could resume an oral diet. However, only 2 patients who underwent surgery resumed an oral diet, and 2 patients required additional EVT. Conclusion Although patients with CA displayed a higher incidence of AL, their rate of successful oral intake exceeded that of those with TA, regardless of treatment method. Among patients exhibiting AL with TA, EVT was more commonly employed than in CA cases, and it appears effective.
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Affiliation(s)
- Hyo Won Seo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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4
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Han D, Tian J, Zhao J, Hao S. Optimal Treatment Strategies for Resectable Locally Advanced Esophageal Squamous Cell Carcinoma: A Real-World Triple Cohort Analysis Using Propensity Score Matching. Int J Gen Med 2023; 16:5467-5479. [PMID: 38021055 PMCID: PMC10676642 DOI: 10.2147/ijgm.s440270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose This study aims to identify the most effective treatment approach and compares the survival rates, along with complications, in patients with locally resectable esophageal squamous cell carcinoma (ESCC) who were treated with one of the three treatment patterns: neoadjuvant chemotherapy followed by surgery (NCT+S), neoadjuvant chemoradiotherapy followed by surgery (NCRT+S), or surgery followed by chemoradiotherapy (S+CRT). Methods We conducted a retrospective analysis of the medical records of ESCC patients who received one of these treatments between March 2015 and March 2022. This analysis aimed to identify differences in long-term survival, pathological responses, and complications across the three treatment groups. To address potential confounding factors, propensity score matching (PSM) and Cox proportional hazards models were utilized. Results This study included a cohort of 715 patients: 197 in the NCT+S group, 188 in the NCRT+S group, and 330 in the S+CRT group, all meeting the selection criteria. After PSM, the median disease-free survival (DFS) time was 38.9 months, 25.6 months, and 15.3 months for NCRT+S, NCT+S, and S+CRT groups, respectively. There were statistically significant differences in the 5-year DFS and 5-year OS among the three groups (P=0.04 and P=0.02, post-matching, respectively). Notably, neoadjuvant therapy showed a correlation with increased postoperative anastomotic leakage rates (17.5% in NCRT+S, 10% in NCT+S, and 5% in S+CRT; P=0.03, post-matching), regardless of the PSM adjustment. Conclusion The findings indicate that neoadjuvant therapy before surgery offers a significant survival advantage over postoperative adjuvant therapy for patients with locally advanced resectable ESCC. Despite similar safety profiles, neoadjuvant therapy appears to be associated with a higher incidence of anastomotic leakage after surgery.
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Affiliation(s)
- Dan Han
- Department of Radiation Oncology, Shandong University Cancer Center, Jinan, Shandong, People’s Republic of China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, and Shandong Academy of Medical Sciences, Jinan, Shandong, People’s Republic of China
| | - Jing Tian
- Department of Radiation Oncology, Jinan Zhangqiu District People’s Hospital, Jinan, Shandong, People’s Republic of China
| | - Junfeng Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, and Shandong Academy of Medical Sciences, Jinan, Shandong, People’s Republic of China
| | - Shaoyu Hao
- Department of Thoracic Surgery, Shandong University Cancer Center, Jinan, Shandong, People’s Republic of China
- Department of Thoracic Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University, and Shandong Academy of Medical Sciences, Jinan, Shandong, People’s Republic of China
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5
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Elliott JA, Klevebro F, Mantziari S, Markar SR, Goense L, Johar A, Lagergren P, Zaninotto G, van Hillegersberg R, van Berge Henegouwen MI, Schäfer M, Nilsson M, Hanna GB, Reynolds JV. Neoadjuvant Chemoradiotherapy Versus Chemotherapy for the Treatment of Locally Advanced Esophageal Adenocarcinoma in the European Multicenter ENSURE Study. Ann Surg 2023; 278:692-700. [PMID: 37470379 DOI: 10.1097/sla.0000000000006018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE This study aimed to compare clinicopathologic, oncologic, and health-related quality of life (HRQL) outcomes following neoadjuvant chemoradiation (nCRT) and chemotherapy (nCT) in the ENSURE international multicenter study. BACKGROUND nCT and nCRT are the standards of care for locally advanced esophageal cancer (LAEC) treated with curative intent. However, no published randomized controlled trial to date has demonstrated the superiority of either approach. METHODS ENSURE is an international multicenter study of consecutive patients undergoing surgery for LAEC (2009-2015) across 20 high-volume centers (NCT03461341). The primary outcome measure was overall survival (OS), secondary outcomes included histopathologic response, recurrence pattern, oncologic outcome, and HRQL in survivorship. RESULTS A total of 2211 patients were studied (48% nCT, 52% nCRT). pCR was observed in 4.9% and 14.7% ( P <0.001), with R0 in 78.2% and 94.2% ( P <0.001) post nCT and nCRT, respectively. Postoperative morbidity was equivalent, but in-hospital mortality was independently increased [hazard ratio (HR)=2.73, 95% CI: 1.43-5.21, P= 0.002] following nCRT versus nCT. Probability of local recurrence was reduced (odds ratio=0.71, 95% CI: 0.54-0.93, P =0.012), and distant recurrence-free survival time reduced (HR=1.18, 95% CI: 1.02-1.37, P =0.023) after nCRT versus nCT, with no difference in OS among all patients (HR=1.10, 95% CI: 0.98-1.25, P =0.113). On subgroup analysis, patients who underwent R0 resection following nCT as compared with nCRT had improved OS (median: 60.7 months, 95% CI: 49.5-71.8 vs 40.8 months, 95% CI: 42.8-53.4, P <0.001). CONCLUSIONS In this European multicenter study, nCRT compared with nCT was associated with reduced probability of local recurrence but reduced distant recurrence-free survival for patients with LAEC, without differences in OS. These data support tailored patient-specific decision-making in the overall approach to achieving optimum outcomes in LAEC.
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Affiliation(s)
- Jessie A Elliott
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
| | - Fredrik Klevebro
- CLINTEC, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Styliani Mantziari
- Lausanne University Hospital CHUV and University of Lausanne UNIL, Lausanne, Switzerland
| | - Sheraz R Markar
- Surgical Interventional Trials Unit, Nuffield Department of Surgery, University of Oxford, Oxford, UK
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Asif Johar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus Schäfer
- Lausanne University Hospital CHUV and University of Lausanne UNIL, Lausanne, Switzerland
| | - Magnus Nilsson
- CLINTEC, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - John V Reynolds
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
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6
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Morse RT, Mouw TJ, Moreno M, Erwin JT, Cao Y, DiPasco P, Al-Kasspooles M, Hoover A. Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy. J Gastrointest Surg 2023; 27:1313-1320. [PMID: 36973500 DOI: 10.1007/s11605-023-05660-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC). METHODS Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA). RESULTS One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01). CONCLUSION Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.
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Affiliation(s)
- Ryan T Morse
- Department of Radiation Oncology, University of North Carolina Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - Tyler J Mouw
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Matthew Moreno
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Jace T Erwin
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Ying Cao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
| | - Peter DiPasco
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Mazin Al-Kasspooles
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Andrew Hoover
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
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7
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Kundel Y, Kurman N, Sulimani O, Gavrielli S, Nachalon Y, Moore A, Kashtan H, Fenig E, Brenner B, Popovtzer A, Fredman E. The effect of gastric fundus radiation dose on postoperative anastomotic leakage in esophageal cancer. Front Oncol 2023; 13:1080089. [PMID: 36925923 PMCID: PMC10011689 DOI: 10.3389/fonc.2023.1080089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023] Open
Abstract
Introduction Standard-of-care treatment for locally advanced esophageal carcinoma (LAEC) includes neoadjuvant chemoradiotherapy followed by esophagectomy. A potentially catastrophic surgical complication is the development of a postoperative anastomotic leak. To date, the association with radiation dose exposure had been inconclusive. We examined the correlation between radiation exposure to the gastric fundus and risk of postoperative leakage using contemporary radiation doses and fractionation. Methods A total of 69 consecutive patients with LAEC who underwent neoadjuvant chemoradiotherapy followed by esophagectomy in our tertiary center were prospectively followed (median, 27 months). Neoadjuvant regimen included 50.4 Gy in 28 fractions with 5-fluorouracil and cisplatin and 41.4 Gy in 23 fractions with carboplatin and paclitaxel. The gastric fundus was contoured and dosimetric and radiation technique parameters were retrospectively evaluated. Results Of the total number of patients, 71% and 29% had esophageal and gastroesophageal junction (GEJ) tumors, respectively. Fourteen patients (20.3%) experienced anastomotic leaks within a median of 2 days postoperatively, 78.6% of whom had lower third esophagus or GEJ primaries. Mean and minimum fundus dose did not significantly differ between those with and those without leakage (p = 0.42, p = 0.51). Mean fundus V25, V30, and V35 doses were numerically but not statistically higher in those with anastomotic leak (p = 0.58, p = 0.39, and p = 0.30, respectively). No correlation with incidence of leakage was seen between 3D and IMRT treatment modalities. Conclusions In our comparatively large prospectively collected series of patients treated for LAEC, radiation dose to the gastric fundus during neoadjuvant combination therapy prior to surgery did not correlate with the risk of postoperative anastomotic leak.
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Affiliation(s)
- Yulia Kundel
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noga Kurman
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Omri Sulimani
- Department of Surgery, Rabin Medical Center, Petach Tikva, Israel
| | - Shlomo Gavrielli
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Yuval Nachalon
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
| | - Assaf Moore
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanoch Kashtan
- Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Rabin Medical Center, Petach Tikva, Israel
| | - Eyal Fenig
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Baruch Brenner
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aron Popovtzer
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elisha Fredman
- Department of Radiation Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv School of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Schlottmann F, Angeramo CA, Bras Harriott C, Casas MA, Herbella FAM, Patti MG. Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2022; 32:380-392. [PMID: 35583556 DOI: 10.1097/sle.0000000000001050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/12/2021] [Indexed: 12/08/2022]
Abstract
BACKGROUND Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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9
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Malthaner RA, Yu E, Sanatani M, Lewis D, Warner A, Dar AR, Yaremko BP, Bierer J, Palma DA, Fortin D, Inculet RI, Fréchette E, Raphael J, Gaede S, Kuruvilla S, Younus J, Vincent MD, Rodrigues GB. The quality of life in neoadjuvant versus adjuvant therapy of esophageal cancer treatment trial (QUINTETT): Randomized parallel clinical superiority trial. Thorac Cancer 2022; 13:1898-1915. [PMID: 35611396 PMCID: PMC9250846 DOI: 10.1111/1759-7714.14433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background We compared the health‐related quality of life (HRQOL) in patients undergoing trimodality therapy for resectable stage I‐III esophageal cancer. Methods A total of 96 patients were randomized to standard neoadjuvant cisplatin and 5‐fluorouracil chemotherapy plus radiotherapy (neoadjuvant) followed by surgical resection or adjuvant cisplatin, 5‐fluorouracil, and epirubicin chemotherapy with concurrent extended volume radiotherapy (adjuvant) following surgical resection. Results There was no significant difference in the functional assessment of cancer therapy‐esophageal (FACT‐E) total scores between arms at 1 year (p = 0.759) with 36% versus 41% (neoadjuvant vs. adjuvant), respectively, showing an increase of ≥15 points compared to pre‐treatment (p = 0.638). The HRQOL was significantly inferior at 2 months in the neoadjuvant arm for FACT‐E, European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ‐OG25), and EuroQol 5‐D‐3 L in the dysphagia, reflux, pain, taste, and coughing domains (p < 0.05). Half of patients were able to complete the prescribed neoadjuvant arm chemotherapy without modification compared to only 14% in the adjuvant arm (p < 0.001). Chemotherapy related adverse events of grade ≥2 occurred significantly more frequently in the neoadjuvant arm (100% vs. 69%, p < 0.001). Surgery related adverse events of grade ≥2 were similar in both arms (72% vs. 86%, p = 0.107). There were no 30‐day mortalities and 2% vs. 10% 90‐day mortalities (p = 0.204). There were no significant differences in either overall survival (OS) (5‐year: 35% vs. 32%, p = 0.409) or disease‐free survival (DFS) (5‐year: 31% vs. 30%, p = 0.710). Conclusion Trimodality therapy is challenging for patients with resectable esophageal cancer regardless of whether it is given before or after surgery. Newer and less toxic protocols are needed.
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Affiliation(s)
- Richard A Malthaner
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Edward Yu
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michael Sanatani
- Medical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Debra Lewis
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Andrew Warner
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - A Rashid Dar
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Brian P Yaremko
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Joel Bierer
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - David A Palma
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Dalilah Fortin
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Richard I Inculet
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Eric Fréchette
- Department of Oncology, Divisions of Thoracic Surgery and Surgical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacques Raphael
- Medical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stewart Gaede
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sara Kuruvilla
- Medical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jawaid Younus
- Medical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mark D Vincent
- Medical Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - George B Rodrigues
- Radiation Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Chou SY, Lu HI, Chen YH, Lo CM, Lin YH, Huang TT, Fang FM, Chen LC, Chen Y, Chiu YC, Chou YP, Li SH, Wang YM. The Radiation Dose to the Left Supraclavicular Fossa is Critical for Anastomotic Leak Following Esophagectomy – A Dosimetric Outcome Analysis. Cancer Manag Res 2022; 14:1603-1613. [PMID: 35530530 PMCID: PMC9075167 DOI: 10.2147/cmar.s354667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/24/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Shang-Yu Chou
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Hao Chen
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yun-Hsuan Lin
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tzu-Ting Huang
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Min Fang
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Li-Chun Chen
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu Chen
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yeh-Pin Chou
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shau-Hsuan Li
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Shau-Hsuan Li, Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Niaosong Dist., Kaohsiung, 833, Taiwan, Tel +886-7-7317123 ext. 8303, Fax +886-7-7322813, Email
| | - Yu-Ming Wang
- Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
- Correspondence: Yu-Ming Wang, Department of Radiation Oncology & Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 129, Ta-Pei Road, Niaosong Dist., Kaohsiung, 833, Taiwan, Tel +886-7-7317123 ext. 7000, Fax +886-7-7322813, Email
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11
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Jung DH, Huh CW, Min YW, Park JC. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022; 95:281-290. [PMID: 34555386 DOI: 10.1016/j.gie.2021.09.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates. METHODS Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract. RESULTS Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself. CONCLUSIONS EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.
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Affiliation(s)
- Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Cheal Wung Huh
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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12
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Harriott CB, Angeramo CA, Casas MA, Schlottmann F. Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis. J Thorac Cardiovasc Surg 2022; 164:e233-e254. [DOI: 10.1016/j.jtcvs.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
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13
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Richter F, Hendricks A, Schniewind B, Hampe J, Heits N, von Schönfels W, Reichert B, Eberle K, Ellrichmann M, Baumann P, Egberts JH, Becker T, Schafmayer C. OUP accepted manuscript. BJS Open 2022; 6:6572150. [PMID: 35451010 PMCID: PMC9023777 DOI: 10.1093/bjsopen/zrac030] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/27/2022] [Accepted: 02/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Anastomotic leakage (AL) after oesophagectomy and oesophageal perforations are associated with significant morbidity and mortality. Minimally invasive endoscopy is often used as first-line treatment, particularly endoluminal vacuum therapy (EVT). The aim was to assess the performance of the first commercially available endoluminal vacuum device (Eso-Sponge®) in the management of AL and perforation of the upper gastrointestinal tract (GIT). Methods The Eso-Sponge® registry was designed in 2014 as a prospective, observational, national, multicentre registry. Patients were recruited with either AL or perforation within the upper GIT. Data were collected with a standardized form and transferred into a web-based platform. Twenty hospitals were enrolled at the beginning of the study (registration number NCT02662777; http://www.clinicaltrials.gov). The primary endpoint was successful closure of the oesophageal defect. Results Eleven out of 20 centres recruited patients. A total of 102 patients were included in this interim analysis; 69 patients with AL and 33 with a perforation were treated by EVT. In the AL group, a closure of 91 per cent was observed and 76 per cent was observed in the perforation group. The occurrence of mediastinitis (P = 0.002) and the location of the defect (P = 0.008) were identified as significant predictors of defect closure. Conclusions The Eso-Sponge® registry offers the opportunity to collate data on EVT with a uniform, commercially available product to improve standardization. Our data show that EVT with the Eso-Sponge® is an option for the management of AL and perforation within the upper GIT.
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Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Alexander Hendricks
- Department of General Surgery, University Hospital Rostock, Rostock, Germany
| | - Bodo Schniewind
- Department of General Surgery and Thoracic Surgery, Hospital of Lueneburg, Lueneburg, Germany
| | - Jochen Hampe
- Medical Department I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Nils Heits
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Witigo von Schönfels
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Benedikt Reichert
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Katrin Eberle
- Department of Internal Medicine, Gastroenterology, Sophien-u. Hufeland Hospital, Weimar, Germany
| | - Mark Ellrichmann
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Petra Baumann
- Aesculap AG, Medical Scientific Affairs, Tuttlingen, Germany
| | | | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Clemens Schafmayer
- Department of General Surgery, University Hospital Rostock, Rostock, Germany
- Correspondence to: Clemens Schafmayer, Department of General Surgery, University Hospital Rostock Schillingallee 35, 18057 Rostock, Germany (e-mail: )
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14
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Nittala R, Niyogi D, Karimundackal G. Generalizability of the Results and Concerns About Leakage Rates of the ICAN Trial. JAMA Surg 2021; 157:175-176. [PMID: 34668961 DOI: 10.1001/jamasurg.2021.5260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rigved Nittala
- Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Devyani Niyogi
- Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - George Karimundackal
- Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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15
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Alfaifi S, Chu R, Hui X, Broderick S, Hooker C, Brock M, Bush E, Hales R, Anderson L, Hoff J, Friedes C, Han-Oh S, Mcnutt T, Ha J, Yang S, Battafarano R, Feliciano J, Voong KR. Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications. Thorac Cancer 2021; 12:3121-3129. [PMID: 34651445 PMCID: PMC8636205 DOI: 10.1111/1759-7714.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Here, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy. Methods Between 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank‐sum tests to compare the association between clinical parameters and anastomotic complications. Results Of 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow‐up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high‐risk subgroup, radiation was not associated with anastomotic complications (p > 0.05). Conclusions Our analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.
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Affiliation(s)
- Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert Chu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Xuan Hui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Craig Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Malcolm Brock
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Errol Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lori Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Hoff
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cole Friedes
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd Mcnutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Yang
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Battafarano
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joy Feliciano
- Departments of Medical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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16
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Zhang G, Zhang C, Sun N, Xue L, Yang Z, Fang L, Zhang Z, Luo Y, Gao S, Xue Q, Mu J, Gao Y, Tan F, He J. Neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy for the treatment of esophageal squamous cell carcinoma: a propensity score-matched study from the National Cancer Center in China. J Cancer Res Clin Oncol 2021; 148:943-954. [PMID: 34013382 DOI: 10.1007/s00432-021-03659-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/03/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The optimal mode of neoadjuvant treatment for esophageal squamous cell carcinoma (ESCC) has not been well characterized. Our study compared neoadjuvant chemotherapy (NCT) with neoadjuvant chemoradiotherapy (NCRT) for patients with ESCC. METHODS Data from ESCC patients receiving NCRT or NCT combined with esophagectomy between 2010 and 2018 from the National Cancer Center in China were retrospectively collected. Long-term survival, pathological response, and perioperative mortality and morbidity were compared between the NCRT and NCT groups. A Cox proportional hazards model and propensity score matching (PSM) were used to minimize bias due to potential confounding. RESULTS Out of 327 eligible patients with ESCC in our study, 90 patients were identified in each group by PSM. The complete pathologic response (pCR) rate in the NCRT group was markedly higher than that in the NCT group (before PSM: 35.1% vs. 6.0%; after PSM: 38.9% vs. 5.6%; both P < 0.001). The rates of 30-day or 90-day mortality were comparable between the two groups, but the NCRT group had a longer postoperative hospital stay (P < 0.001 before PSM and P = 0.012 after PSM) and more postoperative complications (P < 0.001 before PSM and P = 0.014 after PSM), especially, anastomotic leaks (P = 0.001 before PSM and P = 0.013 after PSM). No significant differences in 5-year overall survival (OS) (P = 0.439) or 5-year relapse-free survival (RFS) (P = 0.611) were noted between unmatched groups, but the trend favored NCRT in the propensity score-matched group (77.3% vs. 61.3%; hazard ratio [HR] 1.57; 95% confidence interval [CI] 0.86-2.87; P = 0.141 for OS, and 77.8% vs. 60.5%; HR 1.72; 95% CI 0.95-3.11; P = 0.073 for RFS). Multivariate analysis showed that only ypT and ypN stages were independent predictors of OS before and after PSM (both P < 0.05). CONCLUSION There was no difference in survival between the NCT and NCRT groups, although a trend favored NCRT related to the significantly higher pCR rates. Prospective head-to-head clinical trials to compare these two types of neoadjuvant therapies in ESCC are warranted.
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Affiliation(s)
- Guochao Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Chaoqi Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Nan Sun
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Liyan Xue
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhaoyang Yang
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Lingling Fang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhihui Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yuejun Luo
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Juwei Mu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yushun Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Fengwei Tan
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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17
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Li Y, Liu H, Sun C, Yin X, Tong J, Zhang X, Wang X, Yuan X, Zhang Z, Lu G, Gu Y, Li Y, Huang T, Qiao Z, Chen Y. Comparison of Clinical Efficacy of Neoadjuvant Chemoradiation Therapy Between Lower and Higher Radiation Doses for Carcinoma of the Esophagus and Gastroesophageal Junction: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 111:405-416. [PMID: 33964352 DOI: 10.1016/j.ijrobp.2021.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Neoadjuvant concurrent chemoradiation therapy (nCRT) plus surgery has been a standard treatment for locoregionally advanced esophageal cancer and carcinoma of the gastroesophageal junction (EC/GEJ), but the optimal preoperative radiation dose is still unclear. We performed this systematic review to explore the treatment efficacy and toxicity of different radiation dose levels and find an optimal dose-fractionation strategy in EC/GEJ patients receiving nCRT. METHODS AND MATERIALS Embase and Ovid Medline were searched for articles involving cases of operable squamous and adenocarcinoma of the esophagus and GEJ in which patients received nCRT up to a dose of 50.4 Gy in 28 fractions that were published until July 2019, when the search was performed. Physical dose distributions were converted to biologically equivalent doses (BEDs), which were described in units of gray (alpha/beta). Pooled rates of overall survival (OS), progression-free survival (PFS), failure patterns, and toxicities were compared between lower-dose radiation therapy (LDRT; BED ≤48.85 Gy10) and higher-dose radiation therapy (HDRT; BED >48.85 Gy10) for patients treated with nCRT. RESULTS A total of 110 studies with 7577 EC/GEJ patients receiving nCRT were included in this pooled analysis. Both the PFS and OS rates of patients receiving LDRT were significantly higher than those of patients receiving HDRT. Patients receiving LDRT had improved safety regarding treatment-related adverse events and lower distant failure rates than patients receiving HDRT. Utilization of modern radiation therapy (RT) techniques, including 3-dimensional conformal RT and intensity modulated RT, was associated with improved oncologic outcomes compared with 2-dimensional methods. Subgroup analysis showed that EC/GEJ patients receiving conventionally fractionated radiation to a dose of 40.0 to 41.4 Gy in 20-23 fractions showed improved OS compared with those receiving radiation above this dose. CONCLUSIONS Based on the limited data, nCRT using BED ≤48.85 Gy10 was suitable for locoregionally advanced, resectable EC/GEJ. A total dose of 40.0 to 41.4 Gy in 20 to 23 fractions using modern RT techniques might provide the optimal therapeutic ratio.
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Affiliation(s)
- Ying Li
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Hanshan Liu
- Department of Medical Oncology, Jiangsu Provincial Corps Hospital, Chinese People's Armed Police Forces, Yangzhou City, Jiangsu Province, China
| | - Chao Sun
- Department of Thoracic Surgery, Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Xudong Yin
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Jiandong Tong
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Xizhi Zhang
- Department of Radio-Chemotherapy, Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Xiaolin Wang
- Department of Thoracic Surgery, Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Xin Yuan
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Zhengrong Zhang
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Guangyu Lu
- Department of Epidemiology and Biostatistics, Medical College of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Yixun Gu
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Yongpeng Li
- Department of Medical Oncology, Dalian Medical University, Dalian City, Liaoning Province, China
| | - Tianyu Huang
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China
| | - Zhe Qiao
- Department of Medical Oncology, Dalian Medical University, Dalian City, Liaoning Province, China
| | - Yong Chen
- Department of Radio-Chemotherapy, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou City, Jiangsu Province, China.
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Lo CM, Wang YM, Chen YH, Fang FM, Huang SC, Lu HI, Li SH. The Impact of Radiotherapy Dose in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma Receiving Preoperative Chemoradiotherapy. ACTA ACUST UNITED AC 2021; 28:1354-1365. [PMID: 33805318 PMCID: PMC8025809 DOI: 10.3390/curroncol28020129] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022]
Abstract
Objective: For patients with esophageal squamous cell carcinoma, preoperative chemoradiotherapy followed by planned esophagectomy is used as a curative treatment modality. However, the impact of radiotherapy dose remains undefined. Method: A total of 141 patients with stage III esophageal squamous cell carcinoma (ESCC; as defined by the 7th American Joint Committee on Cancer), receiving preoperative chemoradiotherapy followed by esophagectomy between 2000 and 2015 at Kaohsiung Chang Gung Memorial Hospital, Taiwan, were retrospectively reviewed. The radiotherapy dose of preoperative chemoradiotherapy (36 Gy before 2009 and 50–50.4 Gy after 2009) and other clinicopathological parameters were collected and correlated with the response to chemoradiotherapy and treatment outcome. Result: Of these 141 patients, the radiotherapy dose was 36 Gy in 59 (42%) patients and 50 Gy in 82 (58%) patients. A complete pathological response was noted in 12 (20%) of 59 patients receiving 36 Gy radiotherapy, and 37 (45%) of 82 patients receiving 50 Gy radiotherapy (p = 0.002). The three-year overall survival and disease-free survival rates were 31% and 25% in patients receiving 36 Gy radiotherapy, and 54% and 46% in patients receiving 50–50.4 Gy radiotherapy, respectively (p = 0.023 for overall survival; p = 0.047 for disease-free survival). Multivariate analysis showed that a higher radiotherapy dose was associated with increased pathological complete response (p = 0.003, hazard ratio: 3.215), better overall survival (p = 0.024, hazard ratio: 1.585), and superior disease-free survival (p = 0.049, hazard ratio: 1.493). However, higher radiotherapy doses revealed more surgical complications, including acute respiratory distress syndrome (p = 0.048) and anastomosis leaks (p = 0.004). Conclusion: For patients with locally advanced ESCC, preoperative chemoradiotherapy with higher radiotherapy doses led to increased pathologic complete response rates and improved survival.
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Affiliation(s)
- Chien-Ming Lo
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan;
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan; (Y.-M.W.); (F.-M.F.)
| | - Yen-Hao Chen
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan;
| | - Fu-Min Fang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan; (Y.-M.W.); (F.-M.F.)
| | - Shun-Chen Huang
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan;
| | - Hung-I Lu
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan;
- Correspondence: (H.-I.L.); (S.-H.L.); Tel.: +886-7-7317123 (ext. 8303) (S.-H.L.); Fax: +886-7-7322402 (S.-H.L.)
| | - Shau-Hsuan Li
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Colledge of Medicine, Kaohsiung 833401, Taiwan;
- Correspondence: (H.-I.L.); (S.-H.L.); Tel.: +886-7-7317123 (ext. 8303) (S.-H.L.); Fax: +886-7-7322402 (S.-H.L.)
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Radhakrishna N, Sudha SP, Kalayarasan R, Penumadu P. Does Radiation Dose to Gastric Fundus during Neoadjuvant Chemoradiotherapy for Esophageal Carcinoma Have an Impact on Postoperative Anastomotic Leak? Gastrointest Tumors 2021; 8:121-127. [PMID: 34307310 DOI: 10.1159/000513929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/05/2020] [Indexed: 12/27/2022] Open
Abstract
Background Radiation dose received by the gastric fundus (GF) in neoadjuvant chemoradiotherapy (NACRT) may influence the development of postoperative anastomotic leak (AL) in the management of resectable esophageal carcinoma (EC) by trimodality therapy. The present study aims to evaluate dose-volume parameters of the GF and their association with occurrence of AL in EC. Materials and Methods A retrospective analysis was performed of 27 patients with EC who underwent NACRT followed by esophagectomy with cervical esophagogastric anastomosis between January 2015 and July 2018. The GF was retrospectively contoured; dose-volume parameters of the GF were recorded. Postoperative AL was identified from surgical records. Logistic regression analysis was used to identify risk factors associated with AL. Results The mean age of the patients was 51 ± 10.5 years; 56% (15/27) had involvement of lower 1/3 esophagus, 10/27 (37%) midthoracic esophagus, and 2/27 (7%) upper thoracic esophagus; 40% (11/27) patients developed postoperative AL and 7/11 had distal and 4/11 had mid thoracic esophageal lesions. Four of five (80%) patients treated by 3-dimensional conformal radiotherapy versus 7/22 (32%) patients treated by volumetric modulated arc therapy developed AL (p = 0.12). Univariate logistic regression revealed no significant correlation between Dmean, Dmax, V20, V25, V30, V35, D50, and AL. 8/27 patients underwent ischemic preconditioning of gastric conduit, and 2/8 had AL; 19/27 did not undergo preconditioning, and 9/19 patients experienced AL (p = 0.4). Conclusion There was no significant negative impact of the dose received by the GF in NACRT upon AL rates. Further studies with a larger sample size are required to clarify this issue.
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Affiliation(s)
- Nikhila Radhakrishna
- Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
| | - Shyama Prem Sudha
- Department of Radiation Oncology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), An Institution of National Importance, Government of India, Puducherry, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), An Institution of National Importance, Government of India, Puducherry, India
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), An Institution of National Importance, Government of India, Puducherry, India
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20
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Lai Y, Zeng X, Zhou K, Zhou X, Liu Y, Hu Y. End to end intussusception anastomosis decreases the risk of anastomotic leakage after neoadjvant chemoradiation and McKeown oesophagectomy. Radiother Oncol 2021; 158:285-292. [PMID: 33662437 DOI: 10.1016/j.radonc.2021.02.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE To investigate the relationship between the radiation dose to the anastomotic region and postoperative anastomotic leakage rates after McKeown oesophagectomy with cervical anastomosis. MATERIALS AND METHODS Between January 2017 and December 2019, 164 consecutive patients undergoing trimodal therapy including neoadjuvant chemoradiotherapy and sequential McKeown oesophagectomy were included. The demographic and clinical patient data were collected. Additionally, the radiation dose to the regions including the mediastinum, airway, gastric fundus and anastomotic region was recalculated. RESULTS Twelve patients presented with anastomotic leakage, accounting for 7.3% (12/164) of the cohort. The anastomoses were located in the radiation field for all patients with anastomotic leakage (12/12, 100%), and for 61.8% (94/152) of those without (P = 0.009). Higher radiation doses, including the D50 and the mean, maximal and minimal doses to the oesophageal anastomotic region were found in the anastomotic leak group. Subgroup analysis between patients with end to end (ETE) anastomosis and ETE intussusception anastomosis revealed a lower anastomotic leakage rate in the latter after 1:1 ratio propensity score-matching (10.4% vs. 1.3%, P = 0.034). CONCLUSION Anastomosis location in the radiation field and a higher radiation dose to the oesophageal anastomotic region were associated with the occurrence of anastomotic leakage after trimodal therapy. Compared with ETE anastomosis, ETE intussusception anastomosis might reduce the occurrence of anastomotic leakage after neoadjuvant chemoradiation and subsequent McKeown oesophagectomy.
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Affiliation(s)
- Yutian Lai
- Department of Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xiaoxiao Zeng
- Department of Oncology, the People's Hospital of Jian Yang, Jian Yang, PR China
| | - Kun Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xiaojuan Zhou
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yongmei Liu
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Yang Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, PR China.
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21
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Rozeboom PD, Dyas AR, Bronsert MR, Bhagat R, Meguid RA. Improving postoperative outcomes in esophagectomy for cancer-what is the role of institutional data? J Thorac Dis 2020; 12:1750-1753. [PMID: 32642077 PMCID: PMC7330285 DOI: 10.21037/jtd-20-1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Paul D Rozeboom
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rohun Bhagat
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,University of Rochester, School of Medicine, Rochester, NY, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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22
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Anastomotic complications after esophagectomy: Influence of omentoplasty in propensity-weighted cohorts. J Thorac Cardiovasc Surg 2020; 159:2096-2105. [PMID: 31932061 DOI: 10.1016/j.jtcvs.2019.09.157] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 11/23/2022]
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23
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Commentary: Navigating the perils of neoadjuvant chemoradiation for esophageal surgeons. J Thorac Cardiovasc Surg 2020; 159:2108-2109. [PMID: 31926732 DOI: 10.1016/j.jtcvs.2019.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022]
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Wang L, Milman S, Ng T. Performance of the transoral circular stapler for oesophagogastrectomy after induction therapy. Interact Cardiovasc Thorac Surg 2019; 29:890-896. [PMID: 31436809 DOI: 10.1093/icvts/ivz203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/03/2019] [Accepted: 07/23/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Patients undergoing oesophageal anastomosis may be at an increased risk for leak after induction therapy for oesophageal cancer, with intrathoracic leaks having significant morbidity. The outcomes of utilizing transoral circular stapler for the creation of a thoracic anastomosis have not been well studied in this patient population. METHODS Patients with oesophageal cancer undergoing induction chemotherapy/radiation followed by Ivor Lewis oesophagogastrectomy were evaluated. All thoracic anastomoses were constructed with transoral circular stapler. Primary outcomes evaluated were the rates of anastomotic leak and stricture. RESULTS Over 7 years, 87 consecutive patients were evaluated, among whom 69 (79%) were male. The median age was 63 years, median body mass index (BMI) was 27 kg/m2 and median age-adjusted comorbidity index was 5. Median operative blood loss was 400 ml and median operative time was 300 min. Major complications (grade ≥3) were seen in 19 (22%), including anastomotic leak in 2 (2.3%), both successfully treated with temporary covered metal stent. The median duration of hospital stay was 10 days, and 1 (1.2%) death was reported at 90 days due to cancer recurrence. Stricture occurred in 8 (9.2%), and median time to dilation was 109 days and median number of dilations was 1. Univariable analysis found BMI to be significantly higher in patients with an anastomotic leak versus those without (43 vs 27 kg/m2, P = 0.002). No variables were found to be predictive of anastomotic stricture. CONCLUSIONS The use of the transoral circular stapler for thoracic anastomosis results in a consistent formation of the anastomosis, with low leak and stricture rates in the setting of induction chemotherapy/radiation. Leaks that do occur appear to be amenable to stent therapy.
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Affiliation(s)
- Lily Wang
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Steven Milman
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas Ng
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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25
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Thomas M, Borggreve AS, van Rossum PSN, Perneel C, Moons J, Van Daele E, van Hillegersberg R, Deng W, Pattyn P, Mook S, Boterberg T, Ruurda JP, Nafteux P, Lin SH, Haustermans K. Radiation dose and pathological response in oesophageal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgery: a multi-institutional analysis. Acta Oncol 2019; 58:1358-1365. [PMID: 31432736 DOI: 10.1080/0284186x.2019.1646432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Purpose: To explore whether a higher neoadjuvant radiation dose increases the probability of a pathological complete response (pCR) or pathological major response (pMR) response in oesophageal cancer patients. Material and methods: Between 2000 and 2017, 1048 patients from four institutions were stratified according to prescribed neoadjuvant radiation doses of 36.0 Gy (13.3%), 40.0 Gy (7.4%), 41.4 Gy (20.1%), 45.0 Gy (25.5%) or 50.4 Gy (33.7%) in 1.8-2.0 Gy fractions. Endpoints were pCR (tumour regression grade (TRG) 1) and pMR (TRG 1 + 2). Multivariable binary (TRG 1 + 2 vs. TRG > 2) and ordinal (TRG 1 vs. TRG 2 vs. TRG > 2) logistic regression analyses were performed, with subgroup analyses according to histology (squamous cell carcinoma (SCC) vs. adenocarcinoma (AC)). Variables entered in the regression model along with neoadjuvant radiation dose were clinical tumour stage (cT), histology, chemotherapy regimen, induction chemotherapy and time from neoadjuvant chemoradiation to surgery. Results: A pCR was observed in 312 patients (29.8%); in 22.7% patients with AC and in 49.6% patients with SCC. No radiation dose-response relation was observed for pCR (OR = 1.01, 95% CI: 0.98-1.05 for AC and OR = 1.03, 95% CI: 0.96-1.10 for SCC). A pMR was observed in 597 patients (57.0%); in 53.4% patients with AC and in 67.2% patients with SCC. A higher radiation dose increased the probability of achieving pMR (OR = 1.04, 95% CI: 1.02-1.05). Factors reducing this probability were advanced cT stage (reference = cT1-2; cT3: OR = 0.54, 95% CI: 0.37-0.80; cT4: OR = 0.45, 95% CI: 0.24-0.84), AC histology (reference = SCC; OR = 0.62, 95% CI: 0.44-0.88), the use of non-platinum based chemotherapy in SCC patients (OR = 0.30, 95% CI: 0.10-0.91) and platinum based chemotherapy without induction chemotherapy in patients with AC (OR = 0.56, 95% CI: 0.42-0.76). The radiation dose-response relation was confirmed in a subgroup analysis of histologic subtypes (OR = 1.02, 95% CI: 1.01-1.04 for AC and OR = 1.05, 95% CI: 1.02-1.08 for SCC). Conclusions: Neoadjuvant radiation dose impacts pathological response in terms of pMR in oesophageal cancer patients. No radiation dose-response effect was observed for pCR. Further prospective trials are needed to investigate the dose-response relation in terms of pCR.
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Affiliation(s)
- Melissa Thomas
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven – University Hospitals Leuven, Leuven, Belgium
| | - Alicia S. Borggreve
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter S. N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan Perneel
- Department of Applied Mathematics, Royal Military Academy, Brussels, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, UZ Leuven – University Hospitals Leuven, Leuven, Belgium
| | - Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | | | - Wei Deng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Philippe Nafteux
- Department of Thoracic Surgery, UZ Leuven – University Hospitals Leuven, Leuven, Belgium
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karin Haustermans
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven – University Hospitals Leuven, Leuven, Belgium
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26
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Plum PS, Herbold T, Berlth F, Christ H, Alakus H, Bludau M, Chang DH, Bruns CJ, Hölscher AH, Chon SH. Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy. World J Surg 2019; 43:862-869. [PMID: 30377723 DOI: 10.1007/s00268-018-4832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. METHODS Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. RESULTS Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. CONCLUSIONS The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
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Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - De-Hua Chang
- Institute of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Min YW, Kim T, Lee H, Min BH, Kim HK, Choi YS, Lee JH, Rhee PL, Kim JJ, Zo JI, Shim YM. Endoscopic vacuum therapy for postoperative esophageal leak. BMC Surg 2019; 19:37. [PMID: 30975210 PMCID: PMC6458610 DOI: 10.1186/s12893-019-0497-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023] Open
Abstract
Background Anastomotic leak is the most common and serious complication following esophagectomy. Endoscopic vacuum-assisted closure (EVAC) is a promising method for treating anastomotic leak. We aimed to evaluate the efficacy of EVAC and to identify factors associated with longer treatment duration for esophageal anastomotic leak following esophagectomy for cancer. Methods We retrospectively analyzed 20 esophageal cancer patients who had undergone EVAC for anastomotic leak after esophagectomy. The efficacy and success rates were evaluated and factors associated with longer treatment duration (≥ 21 days) were identified. Results All 20 patients were male. Of these, 10 (50.0%) received neoadjuvant treatment and 6 (30.0%) had one or more comorbidities. The median size of fistula opening was 1.75 cm. During a median of 14.5 days of EVAC treatment, a median of 5 interventions were performed. Treatment success was achieved in 19 patients (95.0%). Neoadjuvant treatment was significantly associated with longer EVAC treatment. There was a non-significant trend toward the need for longer treatment duration for a larger fistula opening size. Conclusions EVAC treatment is a good non-surgical option for anastomotic leak following esophagectomy. Long duration of treatment is associated with neoadjuvant treatment and a large leakage opening.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taewan Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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Klevebro F, Boshier PR, Low DE. Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy. J Thorac Dis 2019; 11:S692-S701. [PMID: 31080646 PMCID: PMC6503292 DOI: 10.21037/jtd.2018.11.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.
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Affiliation(s)
- Fredrik Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Piers R Boshier
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
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Bang A, Broomfield JA, Chan J, Alyamani N, Crnic A, Gilbert S, Pantarotto JR. Radiation dose mapping and anastomotic complications after trimodality therapy for esophageal cancers. Clin Transl Radiat Oncol 2019; 15:76-82. [PMID: 30775562 PMCID: PMC6365800 DOI: 10.1016/j.ctro.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/30/2018] [Accepted: 12/30/2018] [Indexed: 12/29/2022] Open
Abstract
The anastomotic leakage rate was 12% and the stricture rate was 22%. Patients with higher anastomotic complications rates had a significant higher mean dose of radiation to the esophagus below the level of the azygous vein. We did not find a difference in mean gastric doses in patients who did/did not have an anastomotic complication. Anastomotic complications did not affect survival outcomes.
Background and purpose There is conflicting evidence with respect to the correlation between neoadjuvant chemoradiation and anastomotic complications following trimodality therapy in patients with esophageal cancer. We aimed to analyze the relationship between their dosimetry and any resulting anastomotic complications. Materials and methods The medical records of 51 consecutive patients who underwent trimodality therapy between 2007 and 2014 were retrospectively reviewed. We analyzed the differences in the mean dose received by regions of the esophagus relative to the landmark of the azygous vein and the stomach to correlate the development of an anastomotic complication using nonparametric rank-sum tests. Results Anastomotic leakage and stricture rates were 12% and 22%, respectively. Patients with anastomotic complications received a statistically significant higher mean dose to the esophagus at the level of the azygous vein (0.0 cm) and lower (up to −2.7 cm) (28.4–42.2 Gy vs. 10.3–27.6 Gy, p < 0.04). There were no differences noted in mean gastric doses. Median follow up time was 30.9 months. Median overall survival and disease free survival of our patient cohort was 34.4 months and 22.5 months, respectively. The development of an anastomotic complication did not affect survival outcomes. Conclusion Patients who experienced anastomotic complication after trimodality therapy for esophageal cancer were more likely to have received a higher mean esophageal dose around the proximity of the azygous vein, where intrathoracic anastomoses most commonly occur. Communication between surgical and radiation oncologists regarding the anastomotic location may be an important consideration in planning for trimodality therapy in reducing potential anastomotic complications.
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Affiliation(s)
- Andrew Bang
- Division of Radiation Oncology, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.,Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, Ontario M5G 2C1, Canada
| | - Joel A Broomfield
- Division of Radiation Oncology, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Jessica Chan
- Division of Radiation Oncology, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Najlaa Alyamani
- Division of Radiation Oncology, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Agnes Crnic
- Division of Thoracic Surgery, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Jason R Pantarotto
- Division of Radiation Oncology, University of Ottawa. 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
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30
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Meng X, Wang L, Zhao Y, Zhu B, Sun T, Zhang T, Gu X, Zheng Z. Neoadjuvant Chemoradiation Treatment for Resectable Esophago-Gastric Cancer: A Systematic Review and Meta-Analysis. J Cancer 2019; 10:192-204. [PMID: 30662540 PMCID: PMC6329872 DOI: 10.7150/jca.25915] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 10/27/2018] [Indexed: 12/17/2022] Open
Abstract
Background: Neoadjuvant chemoradiation (CRT) remains controversial in the treatment of the oesophagus or gastro-oesophageal junction (GOJ) carcinomas. Methods: We conducted a meta-analysis to assess the efficacy and safety of Neoadjuvant CRT plus surgery comparing with neoadjuvant CT plus surgery or surgery alone. Feasible studies were searched from electronic databases. The outcomes of survival, R0 resection rate and adverse effects were analyzed. The outcomes were measured with relative risk (RR) and odds ratio(OR). Results: Seventeen records including 4095 patients were included. Neoadjuvant CRT improved 1-,2-,3-and 5-year survival. The relative risk (RR) [95% confidence interval (CI),P value] was respectively 1.08(1.03-1.14,0.002), 1.21(1.12-1.32,<0.00001),1.31(1.09-1.58,0.004),1.38(1.17-1.62, <0.001).In subgroup analysis, patients with squamous cell carcinoma benefited more survival advantage from neoadjuvant CRT than those with adenocarcinoma[1.23(1.15-1.33)vs1.11 (1.03-1.19)]. A significant advantage was observed in analysis of neoadjuvant CRT for PFS [1.32 (1.22-1.44),<0.00001]. Tests for DFS between neoadjuvant CRT and neoadjuvant CT or surgery alone were not statistically significant[1.06 (0.97-1.17,0.19)]. Neoadjuvant CRT was associated with higher R0 resection [2.58(1.75-3.82),<0.00001] and pCR rate [4.37(2.68-7.13),<0.00001]. Neoadjuvant CRT lowered the local recurrence rate [0.52(0.39-0.69),<0.00001] and didn't control distant metastasis rate[0.85(0.67-1.08),0.19].There was no evidence that neoadjuvant CRT increased the treatment-related mortality[1.27(0.95-1.71),0.11]. Neoadjuvant CRT plus surgery did not increase the risk of adverse events morbidity[1.14(0.99-1.32),0.08]. Conclusion: Patients with oesophagus or GOJ carcinomas can obtain a survival advantage from neoadjuvant CRT. The addition of radiation was efficacy and safe in range. However, these results need further high-quality prospective RCTs confirmation.
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Affiliation(s)
- Xiangyu Meng
- Department of Gastric Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Lu Wang
- Department of Ultrasonography, the Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yan Zhao
- Department of Gastric Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Bo Zhu
- Department of Information Management, the Information Center, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Ting Sun
- Department of Information Management, the Information Center, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Tao Zhang
- Department of Gastric Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Xiaohu Gu
- Department of Gastric Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
| | - Zhichao Zheng
- Department of Gastric Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital, Shenyang, Liaoning, China
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Ilson DH, van Hillegersberg R. Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus. Gastroenterology 2018; 154:437-451. [PMID: 29037469 DOI: 10.1053/j.gastro.2017.09.048] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 02/07/2023]
Abstract
Esophageal cancer is characterized by early and frequent metastasis. Surgery is the primary treatment for early-stage disease, whereas patients with patients with locally advanced disease receive perioperative chemotherapy or chemoradiotherapy. Squamous cancers can be treated with primary chemoradiotherapy without surgery, depending on their response to therapy and patient tolerance for subsequent surgery. Chemotherapy with a fluorinated pyrimidine and a platinum agent, followed by later treatment with taxanes and irinotecan, provides some benefit. Agents that inhibit the erb-b2 receptor tyrosine kinase 2 (ERBB2 or HER2), or vascular endothelial growth factor, including trastuzumab, ramucirumab, and apatinib, increase response and survival times. Esophageal adenocarcinomas have mutations in tumor protein p53 and mutations that activate receptor-associated tyrosine kinase, vascular endothelial growth factor, and cell cycle pathways, whereas esophageal squamous tumors have a distinct set of mutations. Esophageal cancers develop systems to evade anti-tumor immune responses, but studies are needed to determine how immune checkpoint modification contributes to esophageal tumor development.
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Affiliation(s)
- David H Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York.
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32
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Klevebro F, Ekman S, Nilsson M. Current trends in multimodality treatment of esophageal and gastroesophageal junction cancer - Review article. Surg Oncol 2017; 26:290-295. [PMID: 28807249 DOI: 10.1016/j.suronc.2017.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/25/2017] [Accepted: 06/09/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Multimodality treatment has now been widely introduced in the curatively intended treatment of esophageal and gastroesophageal junction cancer. We aim to give an overview of the scientific evidence for the available treatment strategies and to describe which trends that are currently developing. METHODS We conducted a review of the scientific evidence for the different curatively intended treatment strategies that are available today. Relevant articles of randomized controlled trials, cohort studies, and meta analyses were included. RESULTS After a systematic search of relevant papers we have included 64 articles in the review. The results show that adenocarcinomas and squamous cell carcinomas of the esophagus and gastroesophageal junction are two separate entities and should be analysed and studied as two different diseases. Neoadjuvant treatment followed by surgical resection is the gold standard of the curatively intended treatment today. There is no scientific evidence to support the use of chemoradiotherapy over chemotherapy in the neoadjuvant setting for esophageal or junctional adenocarcinoma. There is reasonable evidence to support definitive chemoradiotherapy as a treatment option for squamous cell carcinoma of the esophagus. CONCLUSION The evidence base for curatively intended treatments of esophageal and gastroesophageal junction cancer is not very strong. Several on-going trials have the potential to change the gold standard treatments of today.
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Affiliation(s)
- Fredrik Klevebro
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
| | - Simon Ekman
- Department of Oncology and Pathology, Karolinska Institutet and Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Superior Thoracic Aperture Size is Significantly Associated with Cervical Anastomotic Leakage After Esophagectomy. World J Surg 2017; 41:2598-2604. [DOI: 10.1007/s00268-017-4047-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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34
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Zhang Z, Zhang H. Impact of neoadjuvant chemotherapy and chemoradiotherapy on postoperative cardiopulmonary complications in patients with esophageal cancer. Dis Esophagus 2017; 30:1-7. [PMID: 28375486 DOI: 10.1093/dote/dox002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Indexed: 02/06/2023]
Abstract
The effectiveness of neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT) for esophageal cancer patients is well established. However, neoadjuvant therapy may induce severe adverse effects that could increase postoperative morbidity. The current study evaluated the impacts of nCT and nCRT on postoperative cardiopulmonary complications in patient with esophageal cancer. We conducted a prospective study in esophageal cancer patients who received nCT (n = 126) or nCRT (n = 141) prior to surgery. Surgery was performed in all these patients following nCT or nCRT treatment. More patients occurred pneumonia in the nCRT-treated group compared with the nCT group (P < 0.01). The E-velocity (early diastolic filling velocity) decreased significantly (P = 0.026), while the N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly increased (P < 0.01) in patients of the nCRT group compared with patients from the nCT group. Furthermore, a multivariate analysis revealed that nCRT was correlated with the incidence of pneumonia and NT-proBNP level significantly. The nCRT caused more cardiopulmonary toxicity than nCT. The strategies are needed to prevent the postoperative cardiopulmonary complications especially in patients with nCRT treatment.
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Affiliation(s)
- Z Zhang
- The Second Hospital of Shandong University, Jinan, China
| | - H Zhang
- Shandong Jiaotong Hospital, Jinan, China
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35
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Abstract
In esophageal cancer surgery, perfusion of the gastric conduit is a critical issue. Measurement of gastric intramucosal pH (pHi) is a method to identify anaerobic metabolism as a sign of impaired perfusion. In this study we aimed to monitor changes in the perfusion of the gastric conduit at key steps during and after esophagectomy. pHi was measured per- and postoperatively using intermittent gastric tonometry in 32 patients undergoing open, 65%, or video-assisted thoracoscopic esophagectomy for esophageal cancer. Measurements focused on the surgical steps when the vascular supply to the gastric conduit was altered. A tonometry catheter was successfully placed in all patients and a decrease in pHi (mean ± SD) was observed from baseline to after the division of the short gastric vessels (7.33 ± 0.07 to 7.29 ± 0.07, P = 0.005). A further reduction after the ligation of the left gastric artery (7.26 ± 0.08, P < 0.001) and after final linear stapling the gastric conduit (7.15 ± 0.13, P < 0.001) was observed. Two hours after surgery, pHi increased (7.24 ± 0.09, P = 0.002). In contrast to open surgery, a trend towards less reduction in pHi was seen in thoracoscopic surgery. Patients with anastomotic leaks had lower pHi on the first postoperative day (7.12 ± 0.05 vs. 7.27 ± 0.08, P = 0.040). It can be concluded that each surgical step altering the vascular supply to the gastric conduit resulted in detectable changes, however transient, in pHi. Patients with low pHi on the first postoperative day were more prone to have clinically relevant anastomotic leaks.
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Affiliation(s)
- Gustav Linder
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Jakob Hedberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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36
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Koëter M, Kathiravetpillai N, Gooszen JA, van Berge Henegouwen MI, Gisbertz SS, van der Sangen MJC, Luyer MDP, Nieuwenhuijzen GAP, Hulshof MCCM. Influence of the Extent and Dose of Radiation on Complications After Neoadjuvant Chemoradiation and Subsequent Esophagectomy With Gastric Tube Reconstruction With a Cervical Anastomosis. Int J Radiat Oncol Biol Phys 2016; 97:813-821. [PMID: 28244418 DOI: 10.1016/j.ijrobp.2016.11.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/12/2016] [Accepted: 11/29/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE To determine, in a large series, the influence of the extent and dose of radiation to the fundus of the stomach and mediastinum on the development and severity of anastomotic complications in patients with esophageal cancer treated with neoadjuvant chemoradiation followed by esophagectomy with cervical anastomosis. METHODS AND MATERIALS Between 2005 and 2012, 364 consecutive patients with esophageal cancer treated with neoadjuvant chemoradiation (41.4 Gy combined with chemotherapy) followed by esophagectomy were included. The future anastomotic region in the fundus was determined, and the mean dose, V20-V40, and upper planning target volume border in relation to mediastinal length, expressed as the mediastinal ratio, were calculated. RESULTS Anastomotic leakage occurred in 22% and anastomotic stenosis in 41%. Logistic regression analysis revealed no influence of age, comorbidity, mean fundus dose, V20-V40, or the mediastinal ratio on the incidence of anastomotic leakage or anastomotic stenosis. In 28% of the patients severe complications (Clavien-Dindo score of ≥IIIB) occurred. The presence of multiple comorbidities (hazard ratio 2.4 [95% confidence interval 1.3-4.5], P=.006) and a mediastinal ratio of 0.5 to 1.0 (hazard ratio 1.9 [95% confidence interval 1.0-3.5], P=.036) were both independent predictors of severe complications. CONCLUSION With a mean radiation dose of 24.2 Gy to the future anastomotic region of the gastric fundus, the radiation dose was not associated with the incidence of anastomotic leakage or anastomotic stenosis. The incidence of severe complications was associated with a high superior mediastinal planning target volume border.
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Affiliation(s)
- M Koëter
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - N Kathiravetpillai
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - J A Gooszen
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - S S Gisbertz
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - M J C van der Sangen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - G A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - M C C M Hulshof
- Department of Radiation Oncology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
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37
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Goense L, van Rossum PSN, Ruurda JP, van Vulpen M, Mook S, Meijer GJ, van Hillegersberg R. Radiation to the Gastric Fundus Increases the Risk of Anastomotic Leakage After Esophagectomy. Ann Thorac Surg 2016; 102:1798-1804. [PMID: 27765168 DOI: 10.1016/j.athoracsur.2016.08.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/20/2016] [Accepted: 08/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Concerns have been raised regarding the toxicity of neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer that could contribute to an increased risk of postoperative complications. The aim of this study was to determine the influence of the radiation dose to the gastric fundus on the risk of postoperative anastomotic leakage in patients undergoing nCRT followed by transthoracic esophagectomy. METHODS Between January 2012 and July 2015, 97 consecutive patients who underwent nCRT followed by transthoracic esophagectomy were included in this single-center cohort study. The gastric fundus was contoured on the pretreatment planning computed tomography. Within this contour, dose-volume histogram variables were calculated, and logistic regression analysis was used to determine their influence on the risk of anastomotic leakage. RESULTS In 25 of 97 patients (26%) anastomotic leakage occurred. The mean radiation dose to the gastric fundus was significantly higher in patients with than without leakage (median 35.6 Gy versus 24.9 Gy, respectively, p = 0.047). A mean dose more than versus less than 31.4 Gy was associated with leakage rates of 43% versus 15%, respectively. Adjusted for tumor location, clinical T stage, and radiation method, the mean radiation dose to the gastric fundus remained significantly and independently associated with an increased risk of anastomotic leakage (adjusted odds ratio 1.05 per 1-Gy increase, 95% confidence interval: 1.002 to 1.10, p = 0.043). CONCLUSIONS Efforts should be made to minimize the radiation dose to the gastric fundus when planning nCRT for esophageal cancer, because higher dose levels to the gastric fundus are associated with an increased risk of anastomotic leakage after subsequent transthoracic esophagectomy and cervical anastomosis.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
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38
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van Workum F, van der Maas J, van den Wildenberg FJH, Polat F, Kouwenhoven EA, van Det MJ, Nieuwenhuijzen GAP, Luyer MD, Rosman C. Improved Functional Results After Minimally Invasive Esophagectomy: Intrathoracic Versus Cervical Anastomosis. Ann Thorac Surg 2016; 103:267-273. [PMID: 27677565 DOI: 10.1016/j.athoracsur.2016.07.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/11/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both cervical esophagogastric anastomosis (CEA) and intrathoracic esophagogastric anastomosis (IEA) are used to restore gastrointestinal integrity following minimally invasive esophagectomy (MIE). No prospective randomized data on functional outcome, postoperative morbidity, and mortality between these techniques are currently available. METHODS A comparison was conducted including all consecutive patients with esophageal carcinoma of the distal esophagus or gastroesophageal junction undergoing MIE with CEA or MIE with IEA from October 2009 to July 2014 in 3 high-volume esophageal cancer centers. Functional outcome, postoperative morbidity, and mortality were analyzed. RESULTS MIE with CEA was performed in 146 patients and MIE with IEA in 210 patients. The incidence of recurrent laryngeal nerve palsy was 14.4% after CEA and 0% after IEA (p < 0.001). Dysphagia, dumping, and regurgitation were reported less frequently after IEA compared with CEA (p < 0.05). Dilatation of benign strictures occurred in 43.8% after CEA and this was 6.2% after IEA (p < 0.001). If a benign stricture was identified, it was dilated a median of 4 times in the CEA group and only once in the IEA group (p < 0.001). Anastomotic leakage for which reoperation was required occurred in 8.2% after CEA and in 11.4% after IEA (not significant). Median ICU stay, hospital stay, in-hospital mortality, 30-day mortality, and 90-day mortality were similar between the groups (not significant). CONCLUSIONS MIE with IEA was associated with better functional results than MIE with CEA with less dysphagia, less benign anastomotic strictures requiring fewer dilatations, and a lower incidence of recurrent laryngeal nerve palsy. Other postoperative morbidity and mortality did not differ between the groups.
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Affiliation(s)
| | - Jolijn van der Maas
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital, Almelo, the Netherlands
| | | | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboudumc, Nijmegen, the Netherlands
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Martínek J, Akiyama JI, Vacková Z, Furnari M, Savarino E, Weijs TJ, Valitova E, van der Horst S, Ruurda JP, Goense L, Triadafilopoulos G. Current treatment options for esophageal diseases. Ann N Y Acad Sci 2016; 1381:139-151. [PMID: 27391867 DOI: 10.1111/nyas.13146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/15/2016] [Accepted: 05/24/2016] [Indexed: 02/06/2023]
Abstract
Exciting new developments-pharmacologic, endoscopic, and surgical-have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barrett's esophagus, since a recent meta-analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot-assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity.
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Affiliation(s)
- Jan Martínek
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic.
| | - Jun-Ichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Zuzana Vacková
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Teus J Weijs
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Elen Valitova
- Department of Upper Gastrointestinal Tract Disorders, Clinical Scientific Centre, Moscow, Russia
| | - Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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40
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Neoadjuvant therapy for advanced esophageal cancer: the impact on surgical management. Gen Thorac Cardiovasc Surg 2016; 64:386-94. [DOI: 10.1007/s11748-016-0655-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/28/2016] [Indexed: 12/18/2022]
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41
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Straatman J, van der Wielen N, Nieuwenhuijzen GAP, Rosman C, Roig J, Scheepers JJG, Cuesta MA, Luyer MDP, van Berge Henegouwen MI, van Workum F, Gisbertz SS, van der Peet DL. Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers. Surg Endosc 2016; 31:119-126. [PMID: 27129563 PMCID: PMC5216077 DOI: 10.1007/s00464-016-4938-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/09/2016] [Indexed: 01/07/2023]
Abstract
Introduction Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL). Methods A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications. Results In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response. Conclusions Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.
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Affiliation(s)
- Jennifer Straatman
- Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam, The Netherlands. .,Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Nicole van der Wielen
- Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Camiel Rosman
- Department of Gastrointestinal Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Josep Roig
- Department of Gastrointestinal Surgery, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Joris J G Scheepers
- Department of Gastrointestinal Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Miguel A Cuesta
- Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Misha D P Luyer
- Department of Gastrointestinal Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Frans van Workum
- Department of Gastrointestinal Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Suzanne S Gisbertz
- Department of Gastrointestinal Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Klevebro F, Friesland S, Hedman M, Tsai JA, Lindblad M, Rouvelas I, Lundell L, Nilsson M. Neoadjuvant chemoradiotherapy may increase the risk of severe anastomotic complications after esophagectomy with cervical anastomosis. Langenbecks Arch Surg 2016; 401:323-31. [DOI: 10.1007/s00423-016-1409-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/14/2016] [Indexed: 11/24/2022]
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Van De Voorde L, Larue R, Persoon L, Öllers M, Nijsten S, Bosmans G, Berbée M, Swinnen A, van Elmpt W, Vanneste B, Verhaegen F, Lambin P. The influence of gastric filling instructions on dose delivery in patients with oesophageal cancer: A prospective study. Radiother Oncol 2015; 117:442-7. [DOI: 10.1016/j.radonc.2015.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/28/2015] [Accepted: 09/06/2015] [Indexed: 12/14/2022]
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Deldycke A, Van Daele E, Ceelen W, Van Nieuwenhove Y, Pattyn P. Functional outcome after Ivor Lewis esophagectomy for cancer. J Surg Oncol 2015; 113:24-8. [PMID: 26525826 DOI: 10.1002/jso.24084] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 10/21/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little is known on functional outcome after Ivor Lewis esophagectomy (ILE) with intrathoracic anastomosis. METHODS Patients who underwent ILE were identified from a prospective database. Clinicopathological data were retrieved and compared with functional outcome data based on patient self-assessment by a standard questionnaire. Predictive factors for selected functional complaints were identified with logistic regression analyses. RESULTS Three hundred and twenty-two patients (80.4% male, mean age 62 years) were studied. Indications for surgery were adenocarcinoma (62.4%), squamous cell carcinoma (28%), and HG Barrett dysplasia (7%). Preoperative chemoradiation (CRT) was administered to 42.5% of patients. Anastomotic leakage occurred in 5.6% and was associated with higher age and diabetes mellitus. Functional symptoms identified were reflux (39%), delayed gastric emptying (37%), dumping (21.4%), and anastomotic stenosis (16%). In the multivariate models, anastomotic stenosis was associated with smaller stapler diameter and presence of esophagitis. Postoperative reflux was associated with higher BMI, whereas dumping was predicted by female gender and age. The quality of life questionnaires revealed a good general health status in 82% of the patients. CONCLUSIONS Functional complaints after ILE consist of reflux, delayed gastric emptying, dumping, and dysphagia, and are affected by age, gender, BMI, diabetes mellitus, and stapler diameter.
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Affiliation(s)
- Annelies Deldycke
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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Lindner K, Fritz M, Haane C, Senninger N, Palmes D, Hummel R. Postoperative complications do not affect long-term outcome in esophageal cancer patients. World J Surg 2015; 38:2652-61. [PMID: 24867467 DOI: 10.1007/s00268-014-2590-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients. METHODS Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study. RESULTS SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival. CONCLUSIONS This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.
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Affiliation(s)
- Kirsten Lindner
- Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Münster, Germany,
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Radiation dose does not influence anastomotic complications in patients with esophageal cancer treated with neoadjuvant chemoradiation and transhiatal esophagectomy. Radiat Oncol 2015; 10:59. [PMID: 25884226 PMCID: PMC4369843 DOI: 10.1186/s13014-015-0361-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/16/2015] [Indexed: 12/18/2022] Open
Abstract
Background Neoadjuvant chemoradiation might increase anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. The aim of this study was to determine the influence of radiation dose on the incidence of leakage and stenosis. Methods Fifty-three patients with esophageal cancer received neoadjuvant chemoradiation (23 × 1.8 Gy) (combined with Paclitaxel and Carboplatin) followed by a transhiatal esophagectomy between 2009 and 2011. On planning CT, the future anastomotic region was determined and the mean radiation dose, V20, V25, V30, V35 and V40 were calculated. Logistic regression analysis was conducted to examine determinants of anastomotic leakage and stenosis. Results Anastomotic leaks occurred in 13 of 53 patients (25.5%) and anastomotic stenosis occurred in 24 of 53 patients (45.3%). Median follow-up was 20 months. Logistic regression analysis showed that mean dose, V20-V40, age, co-morbidity, method of anastomosis, operating time and interval between last radiotherapy treatment and surgery were not predictors of anastomotic leakage and stenosis. Conclusions A radiation dose of 23 × 1.8 Gy on the future anastomotic region has no influence on the occurrence of anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation followed by transhiatal esophagectomy.
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Juloori A, Tucker SL, Komaki R, Liao Z, Correa AM, Swisher SG, Hofstetter WL, Lin SH. Influence of preoperative radiation field on postoperative leak rates in esophageal cancer patients after trimodality therapy. J Thorac Oncol 2015; 9:534-40. [PMID: 24736077 DOI: 10.1097/jto.0000000000000100] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Postoperative morbidities, such as anastomotic leaks, are common after trimodality therapy (chemoradiation followed by surgery) for esophageal cancer. We investigated for factors associated with an increased incidence of anastomotic leaks. METHODS Data from 285 esophageal cancer patients treated from 2000 to 2011 with trimodality therapy were analyzed. Anastomotic location relative to preoperative radiation field was assessed using postoperative computed tomographic imaging. Logistic regression was used to evaluate for factors associated with any or clinically relevant (CR) (≥ grade 2) leaks. RESULTS Overall anastomotic leak rate was 11% (31 of 285), and CR leak rate was 6% (17 of 285). Multivariable analysis identified body mass index (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.00-1.17; OR, 1.11, 95% CI, 1.01-1.22), three-field surgery (OR, 10.01; 95% CI, 3.83-26.21; OR, 4.83; 95% CI, 1.39-16.71), and within radiation field ("in-field") anastomosis (OR, 5.37; 95% CI, 2.21-13.04; OR, 8.63; 95% CI, 2.90-25.65) as independent predictors of both all grade and CR leaks, respectively. While patients with distal esophageal tumors and Ivor-Lewis surgery had the lowest incidence of all grade (6.5%) and CR leaks (4.2%), most of the leaks were associated with the anastomosis constructed within the field of radiation (in-field: 39% and 30% versus out-of-field: 2.6% and 1.0%, respectively, for total and CR leaks, p less than 0.0001, Fisher's exact test). CONCLUSIONS Esophagogastric anastomosis placed within the preoperative radiation field was a very strong predictor for anastomotic leaks in esophageal cancer patients treated with trimodality therapy, among other factors. Surgical planning should include a critical evaluation of the preoperative radiation fields to ensure proper anastomotic placement after chemoradiation therapy.
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Affiliation(s)
- Aditya Juloori
- *Departments of Radiation Oncology, †Bioinformatics and Computational Biology, and ‡Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Van De Voorde L, Larue RT, Pijls M, Buijsen J, Troost EG, Berbée M, Sosef M, van Elmpt W, Schraepen MC, Vanneste B, Oellers M, Lambin P. A qualitative synthesis of the evidence behind elective lymph node irradiation in oesophageal cancer. Radiother Oncol 2014; 113:166-74. [DOI: 10.1016/j.radonc.2014.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/10/2014] [Accepted: 11/09/2014] [Indexed: 12/21/2022]
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Smithers BM, Thomson I. Neoadjuvant Chemotherapy or Chemoradiotherapy for Locally Advanced Esophageal Cancer. Thorac Surg Clin 2013; 23:509-23. [DOI: 10.1016/j.thorsurg.2013.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Wijnhoven BPL, Toxopeus ELA, Vallböhmer D, Knoefel WT, Krasna MJ, Perez K, van Rossum PSN, Ruurda JP, van Hillegersberg R, Schiesser M, Schneider P, Felix VN. New therapeutic strategies for squamous cell cancer and adenocarcinoma. Ann N Y Acad Sci 2013; 1300:213-225. [PMID: 24117644 DOI: 10.1111/nyas.12247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.
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Affiliation(s)
- Bas P L Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eelke L A Toxopeus
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daniel Vallböhmer
- Department of General, Visceral and Pediatric Surgery, University of Düsseldorf, Düsseldorf, Germany
| | - Wolfram T Knoefel
- Department of General, Visceral and Pediatric Surgery, University of Düsseldorf, Düsseldorf, Germany
| | - Mark J Krasna
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Kimberly Perez
- Division of Hematology - Oncology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Peter S N van Rossum
- Departments of Surgery and Radiotherapy, University Medical Center, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Departments of Surgery and Radiotherapy, University Medical Center, Utrecht, The Netherlands
| | | | - Marc Schiesser
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Schneider
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
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