Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with increased risk of recurrence

Comparison of textbook outcomes between laparoscopic and open total gastrectomy for gastric cancer

INTRODUCTION

While surgery remains an important part of the multimodal treatment of gastric cancer, laparoscopy is increasingly being used in these procedures. The aim of our study is to compare open and laparoscopic total gastrectomy using the concept of 'textbook outcome', which has become popular as an important and comprehensive tool in evaluating the quality of surgical treatment.

METHODS

Gastric cancer patients underwent total gastrectomy with curative intent between July 2018 and January 2024 in a single center were included in this retrospective study. Exclusion criteria were emergency surgery, recurrent or metastatic disease, conversion to open, robotic gastrectomy. Patients divided to two groups as open and laparoscopic groups and compared in terms of demographic data, tumor characteristics, operative data and textbook outcome.

RESULTS

A total of 94 patients were enrolled in the study, while the majority of whom were male (73.4%, n = 69). Laparoscopic surgery was found longer but there was no significant difference in the incidence of anastomotic leak and other postoperative complications between the two groups. The textbook outcome rate was 50.8% in the open group while 51.5% in the laparoscopic total gastrectomy group (p = 0.949). The most significant variables associated with the inability to achieve the textbook outcome were readmissions, reinterventions and postoperative complications.

CONCLUSION

Achievement of textbook outcomes was found to be similar between the open and laparoscopic groups. Laparoscopic total gastrectomy can be safely preferred taking into account patient status, surgeon expertise and center conditions.

Multi-Institutional Analysis of Survival and Recurrence Patterns of Different Pathological Regression Types After Neoadjuvant Chemoradiotherapy or Radiotherapy for Esophageal Squamous Cell Carcinoma

BACKGROUND

The recurrence patterns of different types of pathologic regression of the primary tumor and lymph nodes in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (NCRT) are little known, especially in ypT0N+ patients.

METHODS

We included 582 patients with ESCC who had esophagectomy after NCRT or neoadjuvant radiotherapy (NRT) from 3 institutions. The patients were divided into 4 groups: ypT0N0, ypT0N+, ypT+N0, and ypT+N+ according to the type of pathological regression of the primary tumor and lymph nodes. Survival, recurrence pattern and timing, and potential prognostic factors were compared.

RESULTS

A total of 179 patients were classified as ypT0N0, 227 patients as ypT + N0, 45 patients as ypT0N+, and 131 patients as ypT + N+. The median follow-up was 31.7 months in all patients. The restricted mean survival time (RMST) of ypT0N0, ypT + N0, ypT0N+, and ypT + N+ patients decreased sequentially (70.64, 63.84, 55.93 and 39.96 months) and the recurrence rates increased sequentially (22.3%, 29.5%, 44.4% and 54.2%). Both the overall survival (OS) and recurrence-free survival (RFS) in the ypT0N+ group were significantly lower than those in the ypT0N0 group (HR: 2.226, p = 0.007; HR: 2.271, p = 0.003). The distant metastasis (DM) pattern in ypT0N+ was similar to that of ypT + N+, and higher than that of ypN0 (25.6% vs 14.3%, HR: 1.970, p = 0.040).

CONCLUSIONS

ESCC patients with various pathological regression types after receiving NCRT or NRT had significantly different survival rates. ypT0N+ patients had a lower survival rate and higher DM rate than ypT0N0 patients. For these lymph node-positive patients, adjuvant chemotherapy does not appear to improve their prognosis.

Central ligation or partial preservation of the right gastric artery does not seem to affect conduit or anastomotic perfusion during robot-assisted resection of gastroesophageal junction cancer: a randomized clinical trial

The gastric conduit can be created with partial preservation or a central ligation of the right gastric artery. Central ligation may facilitate complete removal of lymph node (LN) station 3; however, whether this influences conduit and anastomotic perfusion is unknown. Hence this study investigated whether a central ligation of the right gastric artery would affect conduit or anastomotic perfusion compared with partial preservation (local standard) during robot-assisted resection of gastroesophageal junction cancer. Patients scheduled for robot-assisted resection of gastroesophageal junction cancer were randomized to either central ligation or partial preservation of the right gastric artery. Perfusion was assessed using quantified indocyanine green angiography: before gastric mobilization, after conduit formation, and after anastomosis. Hemodynamic variables during surgery and surgical outcomes were recorded. We included 70 patients between June 2020 and October 2021, of whom 5 were excluded from the final analysis. The two patient groups did not differ in conduit (0.07 [interquartile range (IQR), 0.05-0.08] vs. 0.07 u [IQR, 0.05-0.08], P = 0.86) or anastomotic perfusion (0.08 [standard deviation (SD), ±0.02] vs. 0.08 u [SD, ±0.02], P = 0.21), nor did they differ in intraoperative blood loss, anastomotic leaks, postoperative complications, or 1-year survival. However, more LNs were resected in the central ligation group (36 [IQR, 30-44] vs. 28 [IQR, 23-43], P = 0.02). Introducing a central ligation of the right gastric artery did not seem to affect conduit or anastomotic perfusion, compared with partial preservation. However, significantly more LNs were resected.

Smoking status predicts anastomotic leak after esophagectomy: a systematic review & meta-analysis

BACKGROUND

Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication.

METHODS

A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test.

RESULTS

A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95% CI 1.18-1.76, I2 = 44%, p < 0.001. Meta-analysis of six studies comparing active smokers alone to never smokers identified a significant increased odds of anastomotic leak (OR 1.80, 95% CI 1.25-2.59, p = 0.002, I2 = 0%). Meta-analysis of five studies comparing ex-smokers to never smokers identified a significant increased odds of anastomotic leak (OR 1.36, 95% CI 1.02-1.82, p = 0.04, I2 = 0%). The odds of anastomotic leak decreased among ex-smokers compared to active smokers.

CONCLUSION

The findings of this systematic review and meta-analysis support the association between positive-smoking status and the risk of anastomotic leak after esophagectomy. Results further emphasize the importance of preoperative smoking cessation to reduce post-operative morbidity.

Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial

Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.

The effect of anastomotic leakage on the incidence of recurrence after tri-modality therapy for esophageal adenocarcinomas

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRTx) reduces the incidence of recurrence, while anastomotic leakage has shown increase the risk of recurrence. The primary objective of this retrospective study was to investigate the incidence and pattern of recurrence and secondary median recurrence-free interval and post-recurrence survival in patients with and without anastomotic leakage after multimodal therapy for esophageal adenocarcinoma.

METHODS

Patients with recurrence after multimodal therapy between 2010 and 2018 were included.

RESULTS

Six hundred and eighteen patients were included, 91 (14.7%) had leakage and 278 (45.0%) recurrence. Patients with leakage did not develop recurrence more often (48.4%) than those without (44.4%, [p = 0.484]). Recurrence-free interval for patients with (n = 44) and without leakage (n = 234) was 39 and 52 weeks, respectively (p = 0.049). Post-recurrence survival was 11 and 16 weeks, respectively (p = 0.702). Specified by recurrence site, post-recurrence survival for loco-regional recurrences was 27 versus 33 weeks (p = 0.387) for patients with and without leakage, for distant 9 versus 13 (p = 0.999), and for combined 11 versus 18 weeks (p = 0.492).

CONCLUSION AND DISCUSSION

No higher incidence of recurrent disease was observed in patients with anastomotic leakage, however it is associated with a shorter recurrence-free interval. This could have implications for surveillance, as early detection of recurrent disease could influence therapeutic options.

Evaluation of the use of inflammatory biomarkers in the early detection of anastomotic leakage after esophagectomy: A retrospective analysis

Background

Postoperative anastomotic leakage remains a major complication of esophagectomy. The development of a reliable method of early detection of anastomotic leakage can revolutionize the management of esophageal carcinoma.

Materials and Methods

This is a retrospective data analysis of 147 patients who underwent Ivor-Lewis esophagectomy as a curative attempt to treat distal esophageal carcinoma in our surgery department between 2010 and 2021. C-reactive protein and white blood cell count in postoperative days 1, 3, 5, and 8 were compared in patients with and without anastomotic leakage. The diagnostic accuracy of these tests was challenged against the clinical reference standard represented by computed tomography or upper gastrointestinal endoscopy.

Results

Twenty-eight patients (19%) developed anastomotic leakage. C-reactive protein values in postoperative day 8 were the only parameter to qualify as a potential clinically helpful test with an area under the receiver operating curve of 0.85 and a P value of less than .01. We calculated the cutoff value for C-reactive protein during postoperative day 8 to be 10.85 mg/dL with specificity and sensitivity of 73.1% and 89.3%, respectively. C-reactive protein showed a positive predictive value of 43.9% and a negative predictive value of 96.7% at this cutoff value.

Conclusion

An absolute diagnostic value of postoperative estimation of serum inflammatory biomarkers to detect anastomotic leakage could not be proved. Serum C-reactive protein on postoperative day 8 with a cutoff value of 10.85 mg/dL could be used to exclude anastomotic leakage after esophagectomy to serve as one of the discharge criteria of the patients.

Phase II Trial Evaluating Esophageal Anastomotic Reinforcement with a Biologic, Degradable, Extracellular Matrix after Total Gastrectomy and Esophagectomy

BACKGROUND

A biologic, degradable extracellular matrix (ECM) has been shown to support esophageal tissue remodeling, which could reduce the risk of anastomotic leak following total gastrectomy and esophagectomy. We evaluated the safety and efficacy of reinforcing the anastomosis with ECM in reducing anastomotic leak as compared to a matched cohort.

STUDY DESIGN

In this single-center, nonrandomized phase II trial, gastric or esophageal adenocarcinoma patients undergoing total gastrectomy or esophagectomy were recruited from November 2013 through December 2018. ECM was surgically wrapped circumferentially around the anastomosis. Anastomotic leak was assessed clinically and by contrast study and defined as clinically significant if requiring invasive treatment (grade 3 or higher). Anastomotic stenosis, other adverse events, symptoms, and dysphagia score were collected by standardized forms at regular follow-up visits at approximately postoperative days (POD) 21 and 90. Patients receiving ECM were compared to a cohort matched for surgery type and age.

RESULTS

ECM placement was not feasible in 9 of 75 patients (12%), resulting in 66 patients receiving ECM. Total gastrectomy was performed in 50 patients (76%) and esophagectomy in 16 (24%). Clinically significant anastomotic leak was diagnosed in 6 of 66 patients (9.1%) (3/50 [6.0%] after gastrectomy, 3/16 [18.8%] after esophagectomy); this rate did not differ from that in the matched cohort (p = 0.57). Stenosis requiring invasive treatment occurred in 8 patients (12.5%), and 10 patients (15.6%) reported not being able to eat a normal diet at POD 90. No adverse events related to ECM were reported.

CONCLUSIONS

Esophageal anastomotic reinforcement after total gastrectomy or esophagectomy with a biologic, degradable ECM was mostly feasible and safe, but was not associated with a statistically significant decrease in anastomotic leak.

Novel Immune-Related Ferroptosis Signature in Esophageal Cancer: An Informatics Exploration of Biological Processes Related to the TMEM161B-AS1/hsa-miR-27a-3p/GCH1 Regulatory Network

Background: Considering the role of immunity and ferroptosis in the invasion, proliferation and treatment of cancer, it is of interest to construct a model of prognostic-related differential expressed immune-related ferroptosis genes (PR-DE-IRFeGs), and explore the ferroptosis-related biological processes in esophageal cancer (ESCA). Methods: Four ESCA datasets were used to identify three PR-DE-IRFeGs for constructing the prognostic model. Validation of our model was based on analyses of internal and external data sets, and comparisons with past models. With the biological-based enrichment analysis as a guide, exploration for ESCA-related biological processes was undertaken with respect to the immune microenvironment, mutations, competing endogenous RNAs (ceRNA), and copy number variation (CNV). The model's clinical applicability was measured by nomogram and correlation analysis between risk score and gene expression, and also immune-based and chemotherapeutic sensitivity. Results: Three PR-DE-IRFeGs (DDIT3, SLC2A3, and GCH1), risk factors for prognosis of ESCA patients, were the basis for constructing the prognostic model. Validation of our model shows a meaningful capability for prognosis prediction. Furthermore, many biological functions and pathways related to immunity and ferroptosis were enriched in the high-risk group, and the role of the TMEM161B-AS1/hsa-miR-27a-3p/GCH1 network in ESCA is supported. Also, the KMT2D mutation is associated with our risk score and SLC2A3 expression. Overall, the prognostic model was associated with treatment sensitivity and levels of gene expression. Conclusion: A novel, prognostic model was shown to have high predictive value. Biological processes related to immune functions, KMT2D mutation, CNV and the TMEM161B-AS1/hsa-miR-27a-3p/GCH1 network were involved in ESCA progression.

Treatment of anastomotic recurrence after esophagectomy

BACKGROUND

Isolated local recurrence after curative esophagectomy for esophageal cancer is a rare event. Although it is potentially curable, management can be challenging.

METHODS

We performed a retrospective review of all patients undergoing esophagectomy for esophageal adenocarcinoma (EAC) from 2000 to 2019. Date of recurrence was defined as the date at which the initial abnormal surveillance study or symptomatic presentation led to further workup and subsequent pathologic diagnosis of recurrence. Overall survival after recurrence was estimated using Kaplan-Meier methods and compared between treatment groups using the log-rank test.

RESULTS

Of the 1370 patients with EAC who underwent esophagectomy in our cohort, 531 (39%) developed recurrence of their disease. The 5-year cumulative incidence of recurrence was 2.7% (95% confidence interval [CI], 2.0%-3.6%) for local, 6.3% (95% CI, 5.2%-7.8%) for regional, and 22.0% (95% CI, 20.0%-24.4%) for distant recurrences. On univariable and multivariable competing-risk regression analysis, advanced pT stage, signet ring histology, and serious complication were independently associated with local recurrence. Patients with local recurrence treated with definitive therapy had a median survival after recurrence of 19.1 months (95% CI, 11.4-33.2 months), compared with 10.6 months (95% CI, 8.5-14.2 months) for chemotherapy or radiotherapy alone and 1.73 months (95% CI, 0.23-15.6 months) for no treatment (P<0.001).

CONCLUSIONS

Isolated local recurrence occurred in only 3% of patients. Advanced T stage, signet cell histology, and serious complication were risk factors for recurrence. Although complex surgical resection is required, in very select cases, more-aggressive treatment may be warranted.

Textbook Outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

OBJECTIVE

Quality assurance is crucial for oncological surgical treatment assessment. For rare diseases, single-quality indicators are not enough. We aim to develop a comprehensive and reproducible measurement, called the "Textbook Outcome" (TO), to assess the quality of surgical treatment and prognosis of gastric neuroendocrine carcinoma (G-NEC) patients.

METHODS

Data from patients with primary diagnosed G-NEC included in 24 high-volume Chinese hospitals from October 2005 to September 2018 were analyzed. TO included receiving a curative resection, ≥15 lymph nodes examined, no severe postoperative complications, hospital stay ≤21 d, and no hospital readmission ≤30 d after discharge. Hospital variation in TO was analyzed using a case mix-adjusted funnel plot. Prognostic factors of survival and risk factors for non-Textbook Outcome (non-TO) were analyzed using Cox and logistic models, respectively.

RESULTS

TO was achieved in 56.6% of 860 G-NEC patients. TO patients had better overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) than non-TO patients (P<0.05). Moreover, TO patients accounted for 60.3% of patients without recurrence. Multivariate Cox analysis revealed non-TO as an independent risk factor for OS, DFS, and RFS of G-NEC patients (P<0.05). Increasing TO rates were associated with improved OS for G-NEC patients, but not hospital volume. Multivariate logistic regression revealed that non-lower tumors, open surgery, and >200 mL blood loss were independent risk factors for non-TO patients (P<0.05).

CONCLUSIONS

TO is strongly associated with multicenter surgical quality and prognosis for G-NEC patients. Factors predicting non-TO are identified, which may help guide strategies to optimize G-NEC outcomes.

Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer by propensity score matching: a retrospective comparative study

PURPOSE

The application of laparoscopic-assisted total gastrectomy (LATG) for resectable gastric cancer (GC) remains controversial compared with open total gastrectomy (OTG), especially for advanced gastric cancer (AGC) patients according to the inconsistent results demonstrated in the previous studies. The aim of this study was to evaluate the short-term and long-term outcomes between LATG and OTG in a population with more than 80% AGC patients by applying propensity score matching (PSM) method.

METHODS

The data of 365 clinical stage I-III GC cases who underwent total gastrectomy with D2 lymphadenectomy were retrospectively collected from January 2011 to April 2018 in the Department of Gastrointestinal Surgery IV of Peking University Cancer Hospital. Propensity scores were generated through taking all covariates into consideration and 131 pairs of patients receiving either LATG or OTG were matched. Intraoperative, postoperative, and survival parameters were compared in the matched groups accordingly. Risk factors for postoperative complications and overall survival were further analyzed.

RESULTS

Patient characteristics in the LATG and OTG groups were well balanced after PSM. LATG showed advantages with respect to shorter time to ambulation, first flatus, and first whole liquid diet intake. No significant differences were found between the two groups with regard to postoperative complications as well as overall survival in terms of different pathological stage. Older age was found as an independent risk factor for postoperative complications, and pathological stage for overall survival as well.

CONCLUSION

LATG appears to have comparable surgical and oncological safety with OTG by experienced surgeons.

Arterial Infusion Chemotherapy for Neoplastic Esophagogastric Anastomotic Strictures After Esophagectomy

Background

Neoplastic esophagogastric anastomotic strictures after resection of esophageal cancer is a very difficult problem in clinical practice. We aim at to investigate the safety and feasibility of arterial infusion chemotherapy in treatment of neoplastic esophagogastric anastomotic strictures after esophagectomy.

Methods

From October 2014 to December 2019, 50 patients with Neoplastic esophagogastric anastomotic strictures after resection of esophageal cancer were assessed retrospectively. Preoperative dysphagia was grade III in 34 cases and grade IV in 16 cases. Thirty-eight patients had different degrees of dyspnea before surgery Twenty-five patients had intolerable (grade IV) dyspnea and airway stenting was undertaken before surgery. Thirteen patients had tolerable dyspnea that did not require airway stenting, and preoperative dyspnea was grade III.

Results

All patients were successfully treated with arterial infusion chemotherapy, no paraplegia or death occurred. The dysphagia grade of 50 patients after AIC was compared: one case had grade I, 40 cases had grade II, and nine cases had grade III. Thirteen patients had tolerable dyspnea that did not necessitate airway stenting. Dyspnea was classified as grade I in five cases and grade II in eight cases. After 1–3 courses of AIC, 50 patients were followed up for a complete response (eight cases), partial response (28) and stable disease (14 cases). Total objective effective rate (complete response+ partial response) and disease control rate(complete response + partial response + stable disease)were 72.0% and 100.0%, respectively. The median duration of follow-up was 8.5 months. One-year survival was 46.0%.

Conclusion

Arterial infusion chemotherapy is safe and efficacious treatment for Neoplastic esophagogastric anastomotic strictures after esophagectomy.

Predictive value of postoperative C-reactive protein-to-albumin ratio in anastomotic leakage after esophagectomy

Introduction

Among the many possible postoperative complications, anastomotic leakage (AL) is the most common and serious. Therefore, the purpose of this study was to explore the ability of various inflammatory and nutritional markers to predict postoperative AL in patients after esophagectomy.

Methods

A total of 273 patients were retrospectively evaluated and enrolled into this study. Perioperative, surgery-related, tumor-related and laboratory tests data were extracted and analyzed. The discriminatory ability and optimal cut-off value was evaluated according to the receiver operating characteristic (ROC) curve analysis. Univariate and multivariate analyses were performed to access the potential risk factors for AL.

Results

The overall incidence of AL was 12.5% (34/273). C-reactive protein-to-albumin ratio (CRP/ALB ratio) [AUC 0.943 (95% confidence interval (CI) = 0.911–0.976, p <  0.001)] and operation time [AUC 0.747 (95% CI = 0.679–0.815, p <  0.001)] had the greatest discrimination on AL prediction. Multivariate analysis demonstrated that CRP/ALB ratio and operation time were two independent risk factors for AL, and CRP/ALB ratio (OR = 102.909, p <  0.001) had an advantage over operation time (OR = 9.363, p = 0.020; Table 3).

Conclusion

Operation time and postoperative CRP/ALB ratio were two independent predictive indexes for AL. Postoperative CRP/ALB ratio greater than 3.00 indicated a high risk of AL. For patients with abnormal postoperative CRP/ALB ratio, early non-operative treatment or surgical intervention are needed to reduce the serious sequelae of AL.

Quantitative fluorescence angiography aids novice and experienced surgeons in performing intestinal resection in well-perfused tissue

Background

Anastomotic leakage (AL) after gastrointestinal resection is a devastating complication with huge consequences for the patient. As AL is associated with poor blood supply, tools for objective assessment of perfusion are in high demand. Indocyanine green angiography (ICG-FA) and quantitative analysis of ICG-FA (q-ICG) seem promising. This study aimed to investigate whether ICG-FA and q-ICG could improve perfusion assessment performed by surgeons of different experience levels.

Methods

Thirteen small bowel segments with a varying degree of devascularization, including two healthy sham segments, were constructed in a porcine model. We recruited students, residents, and surgeons to perform perfusion assessment of the segments in white light (WL), with ICG-FA, and after q-ICG, all blinded to the degree of devascularization.

Results

Forty-five participants fulfilled the study (18 novices, 12 intermediates, and 15 experienced). ICG and q-ICG helped the novices correctly detect the healthy bowel segments to experienced surgeons’ level. ICG and q-ICG also helped novice surgeons to perform safer resections in healthy tissue compared with normal WL. The relative risk (RR) of leaving ischemic tissue in WL and ICG compared with q-ICG, even for experienced surgeons was substantial, intermediates (RR = 8.9, CI95% [4.0;20] and RR = 6.2, CI95% [2.7;14.1]), and experienced (RR = 4.7, CI95% [2.6;8.7] and RR = 4.0, CI95% [2.1;7.5]).

Conclusion

Q-ICG seems to guide surgeons, regardless of experience level, to safely perform resection in healthy tissue, compared with standard WL. Future research should focus on this novel tool’s clinical impact.

Clinical Impact of Sarcopenia on Gastrointestinal Tumors

Preoperative risk stratification in cancer surgery is important to improve treatment and outcome. Sarcopenia is defined by progressive and generalized loss of skeletal muscle mass and strength and is now getting attention as a poor prognostic factor. The purpose of this review was to explore the impact of sarcopenia on short and long-term outcomes in patients undergoing surgical resection of gastrointestinal tumors. Recent studies suggest that sarcopenia contributes to postoperative complications and overall survival. The relatively simple evaluability, as well as its modifiable nature, provides an intriguing potential for sarcopenia to be included in standard preoperative clinical evaluation. Such evaluations can provide physicians with important information to target high-risk individuals with prophylactic measures and eventually improve surgical outcomes.

Sarcopenia as a predictor of postoperative risk of complications, mortality and length of stay following gastrointestinal oncological surgery

INTRODUCTION

Sarcopenia has drawn considerable attention as a predictor of postoperative risk, although the relationship between sarcopenia and postoperative risk is contentious. This meta-analysis was conducted to evaluate this relationship.

METHODS

A systematic literature search up to May 2020 was carried out and 43 studies were identified (with 16,716 patients) reporting on the relationship between sarcopenia and postoperative risk. In order to evaluate this relationship, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the dichotomous and continuous method with a random or fixed effects model.

RESULTS

Compared with non-sarcopenic patients, those with sarcopenia have a higher major complications rate (OR: 4.03, 95% CI: 2.49-5.57, p<0.001), a higher total complications rate (OR: 1.77, 95% CI: 1.40-2.24, p<0.001), a higher 30-day mortality rate (OR: 2.38, 95% CI: 1.56-3.63, p<0.001) and a longer hospital stay (mean difference: 4.54 days, 95% CI: 2.49-6.59 days, p<0.001).

CONCLUSIONS

Sarcopenia significantly increases the risk of major complications, total complications, 30-day mortality and length of hospital stay. For this reason, it is recommended that sarcopenia is added to preoperative risk evaluation to avoid any possible negative outcomes following gastrointestinal oncological surgery.

Surgery by a minimally invasive approach is associated with improved textbook outcomes in oesophageal and gastric cancer

INTRODUCTION

Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival.

METHODS

269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models.

RESULTS

Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters.

CONCLUSION

Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.

A prospective trial of intraoperative tissue oxygenation measurement and its association with anastomotic leak rate after Ivor Lewis esophagectomy

Background

Anastomotic leak following Ivor Lewis esophagectomy is associated with increased morbidity/mortality and decreased survival. Tissue oxygenation at the anastomotic site may influence anastomotic leak. Methods for establishing tissue oxygenation at the anastomotic site are lacking.

Methods

Over a 2-year study period, 185 Ivor Lewis esophagectomies were performed. Study participants underwent measurement of gastric conduit tissue oxygenation at the planned anastomotic site using the wireless pulse oximetry device. Associations between anastomotic leaks or strictures and tissue oxygenation levels were analyzed using Wilcoxon rank sum test or Fisher’s exact test.

Results

Among study participants (n=114), median gastric conduit tissue oxygenation level was 92% (range, 62–100%). There were 8 (7.0%) anastomotic leaks and 3 (2.6%) strictures. Analysis of tissue oxygenation as a continuous variable showed no difference in median tissue oxygenation in patients with and without leaks (98% and 92%; P=0.2) and stricture formation (89% and 92%; P=0.6). Analysis of tissue oxygenation as a dichotomous variable found no difference in anastomotic leak rates [7.5% (n=93) in >80% vs. 0% (n=20) in ≤80%; P=0.3]. There were no significant differences in leak rates in concurrent study nonparticipants.

Conclusions

No significant association was observed between intraoperative tissue oxygenation at the anastomotic site and subsequent anastomotic leak or stricture formation among patients undergoing Ivor Lewis esophagectomy.

Expression of miR-1304 in patients with esophageal carcinoma and risk factors for recurrence

BACKGROUND

Esophageal carcinoma is a malignant gastrointestinal tumor with a very poor prognosis. MicroRNA (miR)-1304 is a newly discovered non-coding RNA, which shows differential expression in other cancers, and its clinical value in esophageal carcinoma remains unclear.

AIM

To explore the expression of miR-1304 in patients with esophageal carcinoma and its clinical value.

METHODS

The expression of miR-1304 in patients with esophageal carcinoma was analyzed based on the data on miR in esophageal carcinoma downloaded from The Cancer Genome Atlas database. Quantitative real-time polymerase chain reaction was adopted to determine the expression of miR-1304 in the tissues and serum of patients. The clinical diagnostic value of miR-1304 and independent factors for recurrence and prognosis of esophageal carcinoma were then analyzed. The potential target genes of miR-1304 were predicted, and then analyzed based on gene ontology, Kyoto Encyclopedia of Genes, and Genomes, and protein-protein interaction.

RESULTS

The expression of miR-1304 in the tissues and serum of patients with esophageal carcinoma increased, and was also increased according to the database. Patients with high expression of miR-1304 suffered increased rates of tumor ≥ 3 cm, low differentiation and stage II + III. miR-1304 had a diagnostic value in identifying esophageal carcinoma, tumor size, differentiation and TNM stage. Tumor size, differentiation, TNM stage, and miR-1304 were independent risk factors for recurrence of esophageal carcinoma, and they had certain predictive and diagnostic value for the recurrence of esophageal carcinoma. Seventy-eight patients showed a 3-year survival rate of 38.46%, and patients with high expression of miR-1304 had a relatively lower survival rate. Multivariate analysis revealed that tumor size, differentiation, recurrence and miR-1304 were independent factors for the prognosis of patients. MiRTarBase, miRDB, and Targetscan predicted 20 target genes in total. Gene ontology enrichment analysis found 18 functions with ^aP < 0.05, and Kyoto Encyclopedia of Genes, and Genomes analysis found 11 signal pathways with ^aP < 0.05. String analysis of protein co-expression found 269 relationship pairs, of which co-expression with epidermal growth factor was the most common.

CONCLUSION

miR-1304 can be used as a potential indicator for the diagnosis and recurrence of esophageal carcinoma and for survival of patients with this disease.

Sarcopenia and Postoperative Complication Risk in Gastrointestinal Surgical Oncology: A Meta-analysis

OBJECTIVE

The aim of the study was to evaluate sarcopenia as a predictor of postoperative risk of major and total complications after surgery for gastrointestinal cancer.

BACKGROUND

Sarcopenia is associated with poor survival in gastrointestinal cancer patients, but the role of sarcopenia as prognostic tool in surgical oncology has not been established, and no consensus exists regarding assessment and management of sarcopenic patients.

METHODS

We performed a systematic search for citations in EMBASE, Web of Science, and PubMed from 2004 to January 31, 2017. Random effects meta-analyses were used to estimate the pooled risk ratio for postoperative complications by Clavien-Dindo grade (total complications: grade ≥2; major complications: grade ≥3) in patients with sarcopenia versus patients without sarcopenia. Stratified analyses were performed by sarcopenia criteria, cutoff level, assessment methods, study quality, cancer diagnosis, and "Enhanced Recovery After Surgery" care.

RESULTS

Twenty-nine studies (n = 7176) were included with sarcopenia prevalence ranging between 12% and 78%. Preoperative incidence of sarcopenia was associated with increased risk of major complications (risk ratio 1.40; 95% confidence interval, 1.20-1.64; P < 0.001; I = 52%) and total complications (risk ratio 1.35; 95% confidence interval, 1.12-1.61; P = 0.001; I = 60%). Moderate heterogeneity was found for both meta-analyses. Subgroup analyses showed that sarcopenia remained a consistent risk factor across stratification by sarcopenia criteria, assessment methods, study quality, and diagnoses.

CONCLUSIONS

Sarcopenia was associated with an increased risk of complications after gastrointestinal tumor resection, but lack of methodological consensus hampers the interpretation and clinical utilization of these findings. Combining assessment of muscle mass with measures of physical function may increase the prognostic value and accuracy in preoperative risk stratification.

Laser speckle contrast imaging and quantitative fluorescence angiography for perfusion assessment

PURPOSE

Indocyanine green fluorescence angiography (ICG-FA) is an established technique for assessment of intestinal perfusion during gastrointestinal surgery, whereas quantitative ICG-FA (q-ICG) and laser speckle contrast imaging (LSCI) are relatively unproven. The study aimed to investigate whether the techniques could be applied interchangeably for perfusion assessment.

METHODS

Nineteen pigs underwent laparotomy, two minor resections of the small bowel, and anastomoses. Additionally, seven pigs had parts of their stomach and small intestine de-vascularized. Data was also collected from an in vivo model (inferior caval vein measurements in two additional pigs) and an ex vivo flow model, allowing for standardization of experimental flow, distance, and angulation. Q-ICG and LSCI were performed, so that regions of interest were matched between the two modalities in the analyses, ensuring coverage of the same tissue.

RESULTS

The overall correlation of q-ICG and LSCI evaluated in the porcine model was modest (rho = 0.45, p < 0.001), but high in tissue with low perfusion (rho = 0.74, p < 0.001). Flux values obtained by LSCI from the ex vivo flow model revealed a decreasing flux with linearly increasing distance as well as angulation to the model. The Q-ICG perfusion values obtained varied slightly with increasing distance as well as angulation to the model.

CONCLUSIONS

Q-ICG and LSCI cannot be used interchangeably but may supplement each other. LSCI is profoundly affected by angulation and distance. In comparison, q-ICG is minimally affected by changing experimental conditions and is more readily applicable in minimally invasive surgery.

Exercise Training in Cancer Control and Treatment

Exercise training is playing an increasing role in cancer care, as accumulating evidence demonstrates that exercise may prevent cancer, control disease progression, interact with anti-cancer therapies, and improve physical functioning and psychosocial outcomes. In this overview article, we present the current state of the field of exercise oncology, which currently comprises of nearly 700 unique exercise intervention trials with more than 50,000 cancer patients. First, we summarize the range of these interventions with regard to diagnoses, clinical setting, timing, and type of intervention. Next, we provide a detailed discussion of the 292 trials, which have delivered structured exercise programs, outlining the impact of exercise training on cancer-specific, physiological, and psychosocial outcomes in the light of the challenges and physiological limitations cancer patients may experience. In summary, the safety and feasibility of exercise training is firmly established across the cancer continuum, and a wide range of beneficial effects on psychosocial and physiological outcomes are well documented. Many of these beneficial effects are linked to the general health-promoting properties of exercise. However, it is becoming increasing evident that exercise training can have direct effects on cancer and its treatment. This calls for future exercise oncology initiatives, which aim to target cancer-specific outcomes, and which are integrated into the concurrent cancer trajectory. Here, the field must bridge extensive knowledge of integrative exercise physiology with clinical oncology and cancer biology to provide a basis of individualized targeted approaches, which may place exercise training as an integrated component of standard cancer care. © 2019 American Physiological Society. Compr Physiol 9:165-205, 2019.

Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction

Background

Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro‐oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients.

Methods

Patients were allocated to a standard‐care control group or an exercise group, who were prescribed standard care plus twice‐weekly high‐intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient‐reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured.

Results

The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy — Esophageal (FACT‐E) total score compared with the baseline level.

Conclusion

Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.

Outcomes of a novel intrathoracic esophagogastric anastomotic technique

OBJECTIVES

Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel "side-to-side: staple line-on-staple line" (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide-diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institution's initial 6-year experience.

METHODS

An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications.

RESULTS

There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end-stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P = .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge.

CONCLUSIONS

We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.

Towards optimal intraoperative conditions in esophageal surgery: A review of literature for the prevention of esophageal anastomotic leakage

BACKGROUND

Esophageal anastomotic leakage (EAL) is a severe complication following gastric and esophageal surgery for cancer. Several non-modifiable, patient or surgery related risk factors for EAL have been identified, however, the contribution of modifiable intraoperative parameters remains undetermined. This review provides an overview of current literature on potentially modifiable intraoperative risk factors for EAL.

MATERIALS AND METHODS

The PubMed, EMBASE and Cochrane databases were searched by two researchers independently. Clinical studies published in English between 1970 and January 2017 that evaluated the effect of intraoperative parameters on the development of EAL were included. Levels of evidence as defined by the Centre of Evidence Based Medicine (CEBM) were assigned to the studies.

RESULTS

A total of 25 articles were included in the final analysis. These articles show evidence that anemia, increased amount of blood loss, low pH and high pCO2 values, prolonged duration of procedure and lack of surgical experience independently increase the risk of EAL. Supplemental oxygen therapy, epidural analgesia and selective digestive decontamination seem to have a beneficial effect. Potential risk factors include blood pressure, requirement of blood products, vasopressor use and glucocorticoid administration, however the results are ambiguous.

CONCLUSION

Apart from fixed surgical and patient related factors, several intraoperative factors that can be modified in clinical practice can influence the risk of developing EAL. More prospective, observational studies are necessary focusing on modifiable intraoperative parameters to assess more evidence and to elucidate optimal values of these factors.

Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients

OBJECTIVE

The objective of this study is to investigate the impact of ketorolac and other nonsteroidal anti-inflammatory drugs on anastomotic leakage after surgery for gastro-esophageal-junction cancer. Within the last two decades, the incidence of gastro-esophageal-junction cancer has increased in the western world and surgery is the curative treatment modality of choice. Anastomotic leakage is a feared complication of gastro-esophageal surgery, as it increases recurrence, morbidity, and mortality. Nonsteroidal anti-inflammatory drugs are widely used for postoperative pain relief. Nonsteroidal anti-inflammatory drugs have, however, in colorectal surgery, been shown to increase the risk of anastomotic leakage.

METHOD

In a historical cohort study, we investigated the impact of nonsteroidal anti-inflammatory drugs on anastomotic leakage in 557 patients undergoing surgery for gastro-esophageal-junction cancer. Data were collected from a prospective maintained database, the Danish National Patient Registry, and patient medical records. Data were analyzed using univariate and multivariate statistical models and were stratified for theoretical confounders.

RESULTS

In univariate analysis, we did not observe any difference in age, gender, tobacco exposure, or comorbidity status between patients experiencing anastomotic leakage and those without. In multivariate analysis, gender, histology, and type of anastomosis proved to affect odds ratios for anastomotic leakage. After adjustment for possible confounders, we found an odds ratio of 6.05 (95% confidence interval 2.71; 13.5) for ketorolac use and of 5.24 (95% confidence interval 1.85; 14.8) for use of other nonsteroidal anti-inflammatory drugs for anastomotic leakage during the first seven postoperative days.

CONCLUSION

In the present study, we found a strong association between the postoperative use of ketorolac and other nonsteroidal anti-inflammatory drugs and the risk for anastomotic leakage after surgery for gastro-esophageal-junction cancers.

Recurrence following curative intended surgery for an adenocarcinoma in the gastroesophageal junction: a retrospective study

Recurrence following a resection for an adenocarcinoma of the gastroesophageal junction leads to reduced long-term survival. This study aims to identify risk factors associated with recurrence, recurrence localization, time to recurrence, and long-term survival. All patients undergoing curative intended resection for an adenocarcinoma of the gastroesophageal junction at Rigshospitalet between June 2003 and December 2011 were identified through a prospectively maintained nationwide database and enrolled in this study. Only histologically verified recurrence was considered eligible. Recurrence within six months, microscopically incomplete resection margins, and death within eight weeks were excluded. A total of 348 patients were included in this study. Biopsy-verified recurrence occurred in 120 patients (34.5%), with 32 local (9.2%), and 88 distant (25.3%) recurrences. Lymph node metastases was associated with an increased risk of recurrence (hazard ratio; [95% confidence interval]: HR = 2.7; [1.7-4.3], P < 0.001). Median time to local versus distant recurrence was 18 months (interquartile range (IQR): 9-37 months) versus 17 months (IQR: 11-27 months), P = 0.96, respectively. A trend toward local recurrence was identified if patients had anastomotic leakage (HR = 2.64; [0.89-7.86], P = 0.08). Survival was inversely associated with recurrence, but a survival comparison between local and distant recurrences showed no significant difference: median survival time was 28 months (IQR: 17-43 months) versus 24 months (IQR: 16-36 months), P = 0.45, respectively. A trend toward local recurrence was seen if the patient had an anastomotic leakage event. However, no factors were associated with site-specific recurrence (local vs. distant).

Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery

BACKGROUND

Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality-of-care parameters and has been developed recently using population-based data. Its association with long-term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long-term survival after treatment for oesophagogastric cancer.

METHODS

All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival.

RESULTS

A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32).

CONCLUSION

Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome.

Comparison of "Nil by Mouth" Versus Early Oral Intake in Three Different Diet Regimens Following Esophagectomy

BACKGROUND

The literature on oral intake after esophagectomy and its influence on anastomotic leakage and complications is sparse.

METHODS

This retrospective study included 359 patients undergoing esophagectomy between January 2011 and August 2015. Three oral intake protocols were evaluated: regimen 1, nil by mouth until postoperative day (POD) 7 followed by a normal diet; regimen 2, oral intake of clear fluids from POD 1 followed by a normal diet; regimen 3, nil by mouth until POD 7 followed by a slow increase to a blended diet. The outcome endpoints were: (1) anastomotic leakage, (2) complications [severity and number described using the Dindo-Clavien Classification and Comprehensive Complication Index (CCI)] and (3) length of stay. A multivariate logistic regression model was obtained for CCI and anastomotic leakage using Wald's stepwise selection.

RESULTS

CCI was significantly lower in regimen 3 (16 vs. 22 and 26 in regimen 1 and 2, p = 0.027). Additionally, significantly fewer patients in regimen 3 suffered from severe complications of Dindo-Clavien grade IIIb-IV (p = 0.025). The incidence of anastomotic leakage reached its lowest in regimen 3, 2%, compared to 7-9%. Multivariate analyses revealed that high American Society of Anesthesiologist score was a predicting factor for both CCI and anastomotic leakage.

CONCLUSION

The study indicates that nil by mouth until postoperative day 7 followed by a slow increase to a blended diet after esophagectomy results in less severe complications and a tendency of fewer anastomotic leakages. Multiple comorbidities proved to be an important predictive factor of the postoperative course.

Management and outcome of cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer

The aim of this study was to evaluate management strategies and related outcomes for cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer with gastric conduit reconstruction. Patients with esophageal cancer undergoing transthoracic esophagectomy with cervical anastomosis from October 2003 to December 2014 were identified from a prospectively acquired database. Management strategies and related outcomes among patients with anastomotic leakage confined to the neck were compared to patients with intrathoracic manifestation of anastomotic leakage. From a total of 286 patients, leakage of the cervical anastomosis occurred in 60 patients (21%) at a median time of 7 days after esophagectomy. Leakage was confined to the neck in 23 of 60 patients (38%), whereas 37 of 60 patients (62%) presented with intrathoracic spread. Leakages with intrathoracic manifestation were more frequently accompanied by a positive SIRS score compared to leakages confined to the neck (73% vs. 35%, respectively; P = 0.004). Drainage of the anastomotic leakage through the neck wound was effective in all of 23 patients (100%) with cervical manifestation. In patients with intrathoracic manifestation, mediastinal drainage through the neck was successful in 15 of 37 patients (41%), whereas 22 patients (59%) required an intervention through the thoracic cavity. Compared to patients with leakage confined to the neck, patients with intrathoracic manifestation showed prolonged intensive care unit (ICU) stay (median 6 vs. 2 days, respectively; P = 0.001), hospital stay (median 34 vs. 19 days, respectively; P < 0.001), and time to oral intake (32 vs. 23 days, respectively; P = 0.018). Intrathoracic manifestation of cervical anastomotic leakage occurs in more than half of patients with anastomotic leakage after transthoracic esophagectomy for cancer. A SIRS reaction should raise the suspicion of intrathoracic spread of leakage. Intrathoracic manifestation can be managed effectively by mediastinal drainage through the neck in 41% of patients, but a reintervention through the thoracic cavity is required in 59%. Intrathoracic manifestation of leakage results in prolonged ICU/hospital stay and delays time to oral intake compared with leakage confined to the neck.

Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives

Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.

The dynamic of nasogastric decompression after esophagectomy and its predictive value of postoperative complications

BACKGROUND

To investigate the regularity and the influence factors of nasogastric decompression volume after esophagectomy, and explore whether the volume of nasogastric decompression can be employed as a predictor for postoperative complications of esophageal carcinoma.

METHODS

Consecutive 247 patients with esophageal cancer who underwent esophagectomy were retrospectively evaluated. The volume of postoperative nasogastric decompression was recorded and the regularity based on it was described. The single and multiple factors regression analysis were used to find out relative factors of the nasogastric decompression volume among the patients without postoperative complication. Gender, age, height, weight, tobacco or alcohol exposure, location of the tumor, histological type, pathological staging, operation time, surgical procedures, anastomotic position and gastric conduit reconstruction were considered as the independent variable. Then, verify the former regression models using the data of patients with postoperative complications.

RESULTS

In trend analysis, the curve estimation revealed a quadratic trend in the relationship between nasogastric decompression volume and postoperative days (R(2) =0.890, P=0.004). The volume of postoperative nasogastric decompression was described by daily drainage (mL) =82.215 + 69.620 × days - 6.604 × days(2). The results of multiple linear stepwise regression analysis showed that gastric conduit reconstruction (β=0.410, P=0.000), smoking (β=-0.231, P=0.000), age (β=-0.193, P=0.001) and histological type of the tumor (β=-0.169, P=0.006) were significantly related to the volume of nasogastric decompression. The average drainage in 5 days after surgery =262.287 + 132.873 × X1 - 72.160 × X2 - 27.904 × X3 - 36.368 × X4 (X1, gastric conduit reconstruction; X2, smoking; X3, histological type; X4, age). The nasogastric decompression of the patients with delayed gastric emptying, and lung infection statistically differ from their predictive values respectively according to the former equation (P<0.01), but the data of anastomotic leakage cases had no significance difference (P=0.344).

CONCLUSIONS

It is found that the volume of postoperative nasogastric decompression presents a quadratic trend based on the days after esophagectomy. Gastric conduit reconstruction, smoking history, age and histological type were independent factors affecting on the volume of postoperative nasogastric decompression. Also, the volume of nasogastric decompression has validity and application value for predicting postoperative complications.

Prolonged postoperative length of stay is associated with poor overall survival after an esophagectomy for esophageal cancer

BACKGROUND

To investigate the impact of prolonged length of stay (LoS) on long-term mortality in patients who have undergone curative resection for esophageal cancer (EC).

METHODS

Between January 2001 and December 2009, patients who underwent an esophagectomy for EC at Fudan University Shanghai Cancer Center were enrolled in this study. We retrospectively analyzed the medical charts of all of the enrolled patients. To determine the effect of postoperative LoS on long-term survival, we separated the patients into three groups based on the lengths of their postoperative LoS, including an LoS of less than 2 weeks (Group 1, ≤2 W), an LoS between 2 and 3 weeks (Group 2, ≤3 W) and an LoS of more than 3 weeks (Group 3, >3 W). Perioperative and long-term outcomes were compared between the groups.

RESULTS

In total, 348 patients were included in this study. All of the patients underwent an esophagectomy with 3-field lymph node dissection (3FLND). The median postoperative hospital stay was 14 days (range: 8-153 days). Complications were observed in 123 patients (15.9% in Group 1 vs. 73.2% in Group 2 vs. 96.6% in Group 3, P<0.001). The median duration of follow-up was 39 months (range: 3-120 months). There were significant reductions in preventive adjuvant therapy (P=0.003) and postoperative salvage therapy (P<0.001) among the three groups. The 5-year survival rate was significantly different among the groups (43% vs. 36% vs. 29%, respectively, P=0.006). There was no difference in the 5-year disease-free survival rate among the three groups (23% vs. 21% vs. 19%, P=0.238).

CONCLUSIONS

Prolonged LoS was significantly associated with reduced rates of overall survival (OS). The insufficient administration of adjuvant therapy may partly account for these findings.