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

Association of operative time and approach on postoperative complications for esophagectomy

BACKGROUND

Minimally invasive esophagectomy is associated with decreased postoperative complications compared with open esophagectomy. However, the risks of complications for minimally invasive esophagectomy compared with open esophagectomy may be affected by operative time. The objectives of this study are to (1) compare the incidence of postoperative complications for minimally invasive esophagectomy and open esophagectomy and (2) evaluate the association of postoperative complications on operative approach and operative time.

METHODS

A retrospective cohort analysis of patients who underwent an esophagectomy in the American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Data File was performed from 2016 to 2020. For analysis, minimally invasive esophagectomy and open esophagectomy were stratified into tertiles of operative time. A bivariate analysis of postoperative complications comparing minimally invasive esophagectomy with open esophagectomy was performed. Multivariable Poisson regression models were estimated evaluating the association of the likelihood of postoperative complications with operative approach and operative time.

RESULTS

In total, 8,574 patients who underwent esophagectomy were included: 5,369 patients underwent minimally invasive esophagectomy, and 3,205 patients underwent open esophagectomy. Median operative time was 402 minutes for minimally invasive esophagectomy and 321 minutes for open esophagectomy. The incidence of postoperative complications and 30-day mortality was lower in the minimally invasive esophagectomy group than the open esophagectomy group within the same tertiles of operative time. When we compared patients who underwent short open esophagectomy with those who underwent long minimally invasive esophagectomy, there were no significant differences in complications.

CONCLUSION

There is no significant association of postoperative complications for short open esophagectomy compared with long minimally invasive esophagectomy. Patients should be selected for minimally invasive esophagectomy when there is appropriate surgeon experience and hospital resources.

Prediction of Anastomotic Leakage in Esophageal Cancer Surgery: A Multimodal Machine Learning Model Integrating Imaging and Clinical Data

RATIONALE AND OBJECTIVES

Surgery in combination with chemo/radiotherapy is the standard treatment for locally advanced esophageal cancer. Even after the introduction of minimally invasive techniques, esophagectomy carries significant morbidity and mortality. One of the most common and feared complications of esophagectomy is anastomotic leakage (AL). Our work aimed to develop a multimodal machine-learning model combining CT-derived and clinical data for predicting AL following esophagectomy for esophageal cancer.

MATERIAL AND METHODS

A total of 471 patients were prospectively included (Jan 2010-Dec 2022). Preoperative computed tomography (CT) was used to evaluate celia trunk stenosis and vessel calcification. Clinical variables, including demographics, disease stage, operation details, postoperative CRP, and stage, were combined with CT data to build a model for AL prediction. Data was split into 80%:20% for training and testing, and an XGBoost model was developed with 10-fold cross-validation and early stopping. ROC curves and respective areas under the curve (AUC), sensitivity, specificity, PPV, NPV, and F1-scores were calculated.

RESULTS

A total of 117 patients (24.8%) exhibited post-operative AL. The XGboost model achieved an AUC of 79.2% (95%CI 69%-89.4%) with a specificity of 77.46%, a sensitivity of 65.22%, PPV of 48.39%, NPV of 87.3%, and F1-score of 56%. Shapley Additive exPlanation analysis showed the effect of individual variables on the result of the model. Decision curve analysis showed that the model was particularly beneficial for threshold probabilities between 15% and 48%.

CONCLUSION

A clinically relevant multimodal model can predict AL, which is especially valuable in cases with low clinical probability of AL.

Relationship Between Preoperative Nutritional Indicators and Postoperative Complications in Patients with Oesophageal Cancer: A Meta-Analysis

Nutritional status is an essential factor in the occurrence of complications in patients with esophageal cancer. We sought to assess the relationship between malnutrition and complications using various nutritional assessment indicators. We conducted a comprehensive literature search of medical databases for articles published up to July 2023. The primary outcome indicator is the occurrence of complications, for which we combined 95% confidence intervals (CIs) and odds ratios (ORs) for postoperative complications and analyzed them using a random effects model. The analysis was carried out using STATA15.0 software. A total of 33 study groups from 22 publications with 5,675 subjects were included. Pooled results show that nutritional indicators are strongly correlated with the occurrence of postoperative complications (OR = 1.45, 95% CI: 1.30-1.62). In the subgroup analyses, comprehensive indicators and the skeletal muscle index were significantly associated with complications, whereas laboratory indicators were not associated with complications (comprehensive indicators OR = 2.68, 95% CI: 1.80-4.00; skeletal muscle index OR = 2.93, 95% CI: 1.44-5.99; laboratory indicators OR = 1.05, 95% CI: 0.96-1.16). Patients with normal body mass index and hospitalized patients were more likely to develop complications. Malnutrition is strongly associated with the development of complications. Nutritional indicators and patient characteristics influenced this relationship.

Multi-disciplinary management of esophageal carcinoma: Current practices and future directions

Esophageal cancer in one of the most malignant and hard-to-treat cancers. Esophageal squamous carcinoma (ESCC) is most common in Asian countries, whereas adenocarcinoma at the esophago-gastric junction (EGJ AC) is more prevalent in the Western countries. Due to differences in both genetic background and response to chemotherapy and radiotherapy, both histologic subtypes need different paradigms of management. Since the landmark CROSS study has demonstrated the superior survival benefit of tri-modality including neoadjuvant chemoradiotherapy prior to esophagectomy, the tri-modality becomes the standard of care; however, it is suitable for a highly-selected patient. Tri-modality should be offered for every ESCC patient, if a patient is fit for surgery with adequate cardiopulmonary reserve, regardless of ages. Definitive chemoradiotherapy remains the best option for a patient who is not a surgical candidate or declines surgery. On the contrary, owing to doubtful benefits of radiotherapy with potentially more toxicities related to radiotherapy in EGJ AC, either neoadjuvant chemotherapy or peri-operative chemotherapy would be more preferable in an EGJ AC patient. In case of very locally advanced disease (cT4b), the proper management is more challenging. Even though, palliative care is the safe option, multi-modality therapy with curative intent like neoadjuvant chemotherapy with conversion surgery may be worthwhile; however, it should be suggested on case-by-case basis.

Intraoperative Laparoscopic Hyperspectral Imaging during Esophagectomy-A Pilot Study Evaluating Esophagogastric Perfusion at the Anastomotic Sites

Hyperspectral imaging (HSI) is a non-invasive and contactless technique that enables the real-time acquisition of comprehensive information on tissue within the surgical field. In this pilot study, we investigated whether a new HSI system for minimally-invasive surgery, TIVITA® Mini (HSI-MIS), provides reliable insights into tissue perfusion of the proximal and distal esophagogastric anastomotic sites during 21 laparoscopic/thoracoscopic or robotic Ivor Lewis esophagectomies of patients with cancer to minimize the risk of dreaded anastomotic insufficiency. In this pioneering investigation, physiological tissue parameters were derived from HSI measurements of the proximal site of the anastomosis (esophageal stump) and the distal site of the anastomosis (tip of the gastric conduit) during the thoracic phase of the procedure. Tissue oxygenation (StO2), Near Infrared Perfusion Index (NIR-PI), and Tissue Water Index (TWI) showed similar median values at both anastomotic sites. Significant differences were observed only for NIR-PI (median: 76.5 vs. 63.9; p = 0.012) at the distal site (gastric conduit) compared to our previous study using an HSI system for open surgery. For all 21 patients, reliable and informative measurements were attainable, confirming the feasibility of HSI-MIS to assess anastomotic viability. Further studies on the added benefit of this new technique aiming to reduce anastomotic insufficiency are warranted.

Outcomes of early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophageal cancer surgery: a randomized clinical trial

BACKGROUND

This study aims to investigate the outcomes of patients who received early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy due to esophageal cancer.

METHODS

A prospective randomized clinical trial was performed between March 2020 and June 2022. Patients who were scheduled for thoracoscopic and laparoscopic esophagectomy due to esophageal cancer were enrolled. Then, these patients were assigned to the control group (traditional postoperative care) and study group (traditional postoperative care with early bronchoscopic sputum aspiration and lavage). The outcomes, which included the length of hospital stay and medical expenses, and postoperative complications, which included pulmonary infection, atelectasis, respiratory dysfunction and anastomotic leakage, were compared between these two groups.

RESULTS

A total of 106 patients were enrolled for the present study, and 53 patients were assigned for the control and study groups. There were no statistically significant differences in gender, age, and location of the esophageal cancer between the two groups. Furthermore, the length of hospital stay was statistically significantly shorter and the medical expenses were lower during hospitalization in the study group, when compared to the control group (12.3 ± 1.2 vs. 18.8 ± 1.3 days, 5.5 ± 0.9 vs. 7.2 ± 1.2 Chinese Yuan, respectively; all, P < 0.05). Moreover, there were statistically significantly fewer incidences of overall complications in study group, when compared to the control group (20.7% vs.45.2%, P < 0.05).

CONCLUSIONS

For patients with esophageal cancer, early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy can shorten the length of hospital stay, and lower the medical expense and incidence of postoperative complications.

Minimally invasive versus open esophagectomy after neoadjuvant therapy for esophageal cancer: a meta-analysis

OBJECTIVES

Neoadjuvant therapy and minimally invasive esophagectomy (MIE) are widely used in the comprehensive treatment of esophageal cancer. This study aimed to investigate the advantages of MIE for esophageal cancer after neoadjuvant therapy.

METHODS

Published clinical studies were reviewed and survival data and safety data were extracted. We compared the long-term survival and safety of MIE versus open esophagectomy after neoadjuvant surgery in a series of meta-analyses.

RESULTS

6 retrospective studies were included. Overall, MIE could significantly improve the overall survival of patients with esophageal cancer after neoadjuvant therapy compared with open esophagectomy [hazard ratio (HR) = 0.86, 95% confidence interval (CI) (0.75, 0.98)]. Compared with open esophagectomy, MIE could significantly reduce intraoperative blood loss and operative time [mean difference (MD) = -40.28.78, 95% CI (- 62.98, - 17.58); MD = -28.78, 95% CI (- 42.48, - 15.07), respectively]. There was no significant difference in 30-day and 90-day mortality between MIE and open esophagectomy [odds ratio (OR) = 0.42, 95% CI (0.09, 2.01); OR 0.80, 95% CI (0.25, 2.60), respectively]. MIE could not significantly reduce the incidence of anastomotic leakage, recurrent laryngeal nerve palsy and chylothorax [OR 0.70, 95% CI (0.37, 1.32); OR 1.43, 95% CI (0.33, 6.25); HR = 1.79, 95% CI (0.67, 4.75), respectively], but the incidence of pneumonia was significantly reduced [HR = 0.43, 95% CI (0.22, 0.82)]. In addition, the length of hospital stay and the incidence of total complications were significantly reduced after MIE [MD = -2.61, 95% CI (- 3.10, - 2.12); HR = 0.66, 95% CI (0.45, 0.98), respectively].

CONCLUSION

MIE after neoadjuvant therapy is effective and safe. Compared with open esophagectomy, MIE can improve the long-term survival and reduce the incidence of postoperative complications of esophageal cancer patients.

Successful management of therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up: A case report

BACKGROUND

Gastric pull-up after esophagectomy is still a demanding surgical procedure and associated with considerable morbidity such as anastomotic leaks, fistulas or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperations may be necessary. Here, we report managing therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up.

CASE SUMMARY

A 70-year-old male with dysphagia and regurgitation after esophagectomy with gastric pull-up reconstruction was transferred to our tertiary hospital. Since endoscopic approaches including balloon dilatation and stenting failed, retrosternal colonic pull-up with Roux-en-Y reconstruction was performed with no subsequent adverse events.

CONCLUSION

Secondary colonic pull-up is a demanding but successful surgical procedure in patients suffering from therapy-refractory complaints after esophagectomy with gastric pull-up reconstruction.