Quality of Life After an Esophagectomy

Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2)

BACKGROUND

Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL.

METHODS

Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included.

RESULTS

A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients.

CONCLUSION

The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Long-term quality of life after hybrid robot-assisted and open Ivor Lewis esophagectomy for esophageal cancer in a single center: a comparative analysis

PURPOSE

Due to improved survival of esophageal cancer patients, long-term quality of life (QoL) is increasingly gaining importance. The aim of this study is to compare QoL outcomes between open Ivor Lewis esophagectomy (Open-E) and a hybrid approach including laparotomy and a robot-assisted thoracic phase (hRob-E). Additionally, a standard group of healthy individuals serves as reference.

METHODS

With a median follow-up of 36 months after hRob-E (n = 28) and 40 months after Open-E (n = 43), patients' QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30 (QLQ-C30) and the EORTC Esophagus specific QoL questionnaire 18 (QLQ-OES18).

RESULTS

Patients showed similar clinical-pathological characteristics, but hRob-E patients had significantly higher ASA scores at surgery (p < 0.001). Patients and healthy controls reported similar global health status and emotional and cognitive functions. However, physical functioning of Open-E patients was significantly reduced compared to healthy controls (p = 0.019). Operated patients reported reduced role and social functioning, fatigue, nausea and vomiting, dyspnea, and diarrhea. A trend towards a better pain score after hRob-E compared to Open-E emerged (p = 0.063). Regarding QLQ-OES18, hRob-E- and Open-E-treated patients similarly reported eating problems, reflux, and troubles swallowing saliva.

CONCLUSIONS

The global health status is not impaired after esophagectomy. Despite higher ASA scores, QoL of hRob-E patients is similar to that of patients operated with Open-E. Moreover, patients after hRob-E appear to have a better score regarding physical functioning and a better pain profile than patients after Open-E, indicating a benefit of minimally invasive surgery.

Role of surgery following neoadjuvant chemoradiation in patients with lymph node positive locally advanced esophageal adenocarcinoma: a national cancer database analysis

Background

Concurrent chemoradiation (CRT) followed by surgery is a standard of care for locally advanced esophageal adenocarcinoma. It remains unclear if surgery following CRT offers any meaningful survival benefit compared to CRT alone in patients with clinical N3 disease who are at the highest risk of developing distant disease relapse.

Methods

We conducted analysis of the National Cancer Database (NCDB) to compare overall survival (OS) of patients with locally advanced esophageal adenocarcinoma (cTanyN1-3M0 based on AJCC 7th staging system) who underwent CRT with or without surgery and analyzed outcomes based on the cN stage.

Results

7,520 patients were included in the analysis-74.7% had cN1 disease, 21.1% had cN2 disease, and 4.3% had cN3 disease. The median OS advantage offered by CRT followed by surgery was 22, 15.8, and 9.6 months compared to CRT alone in cN1, cN2, and cN3 patients, respectively. The 5-year OS estimates in the surgical group were 36.9%, 31.6% and 15.9% in cN1, cN2 and cN3 groups, respectively.

Conclusions

Surgery following CRT in patients with locally advanced esophageal adenocarcinoma leads to improvement in OS, with the largest benefit noted in patients with cN1 and cN2 disease. Surgery following CRT also confers meaningful long-term survival advantage for a subset of cN3 patients.

Variation in Diagnosis, Treatment, and Outcome of Esophageal Cancer in a Regionalized Care System in Ontario, Canada

IMPORTANCE

Esophageal cancer remains one of the most deadly cancers, ranking sixth highest among cancers leading to the greatest years of life lost.

OBJECTIVE

To determine how patients with esophageal cancer are diagnosed and treated in Ontario's regionalized thoracic surgery centers.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients diagnosed with esophageal cancer between January 1, 2010, and December 31, 2018, identified from the Ontario Cancer Registry, in a single-payer health care system with regionalization of thoracic surgery in the province of Ontario, Canada.

EXPOSURES

Exposures included incidence of esophageal cancer and stage at diagnosis; time from the first health care visit until treatment; and the use of specialist consultations, endoscopic ultrasonography, positron emission tomography and computed tomography, endomucosal resection, esophagectomy, neoadjuvant therapy, adjuvant therapy, radiation alone, and chemotherapy alone or in combination with other treatment.

MAIN OUTCOMES AND MEASURES

Outcome measures included wait times, health care use, treatment, and overall survival. Data were analyzed from March 2020 to February 2021.

RESULTS

There were 10 364 patients (mean [SD] age, 68.3 [11.9] years; 7876 men [76%]) identified during the study period. The incidence of esophageal cancer increased over the study period from 1041 in 2010 to 1309 in 2018, which was driven by a 30% increase in the number of adenocarcinomas. The time from first health care encounter to start of treatment was a median 93 days (interquartile range, 56-159 days). Endoscopic ultrasonography was observed for 12% of patients, and positron emission tomography and computed tomography (CT) in 45%. Use of endoscopic mucosal resection was observed for 8% of patients with stage 0 to I disease. A total of 114 of 547 patients (21%) receiving endoscopic resection had a subsequent esophagectomy. Only 2778 patients (27%) had consultations with a thoracic surgeon, a medical oncologist, and a radiation oncologist, whereas 1514 patients (15%) did not see any of these specialists. Of 3047 patients who had an esophagectomy, those receiving neoadjuvant therapy had better overall survival (median survival, 36 months; 95% CI, 32-39 months) than patients who received esophagectomy alone (median survival, 27 months; 95% CI, 24-30 months) or those who received esophagectomy with adjuvant therapy (median survival, 36 months; 95% CI, 32-44 months) despite significant early mortality (log-rank P < .001). There was significant variation in treatment modality across hospitals: esophagectomy ranged from 5% to 39%; esophagectomy after neoadjuvant therapy ranged from 33% to 93%; and esophagectomy followed by adjuvant therapy ranged from 0 to 34% (P < .001). Perioperative mortality was higher at 30 days for patients receiving esophagectomy at low-volume centers (odds ratio [OR], 3.66; 95% CI, 2.01-6.66) and medium-volume centers (OR, 2.07; 95% CI, 1.33-3.23) compared with high-volume centers (P < .001). A longer wait time until treatment was associated with better overall survival (median overall survival was 15 to 17 days vs 5 to 8 days for patients who received treatment earlier than 30 days vs 30 days or longer after diagnosis; P < .001).

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that despite regionalization, there was significant regional variability in volumes at designated centers and in the evaluation and treatment course for patients with esophageal cancer across Ontario.

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Current Outcome of Esophagectomy in the Very Elderly: Experience of a German High-volume Center

Operative management of esophageal carcinoma in the very elderly is still controversially discussed. It is not yet decided whether the risk warrants the procedure. The aim of this study is to analyze the outcome of esophagectomy for esophageal cancer in the very elderly. Factors influencing the clinical course and determining the outcome are identified. A retrospective study 292 consecutive cases of esophagectomy for nonmetastatic esophageal cancer at a German tertiary referral hospital between 2004 and 2011 were reviewed. Two age groups (75 years or older and younger than 75 years) were formed. The mean age was 63 years. Altogether 45 patients were 75 years or older. There were no significant differences in American Society of Anesthesiologists score, operative procedure, or in the frequency of anastomotic leakage between the age groups. However, very elderly patients with anastomotic leak had an eight times higher risk for fatal outcome than the very elderly without leak (odds ratio [OR], 8.54; 95% confidence interval [CI], 1.0 to 112.18; P = 0.025). Moreover, the odds for postoperative death were five times higher in very elderly patients with leak than in younger patients sustaining anastomotic leakage (OR, 5.67; 95% CI, 0.67 to 73.83; P = 0.046). In general, the very elderly had a three times higher risk for a fatal outcome (OR, 3.30; 95% CI, 1.37 to 7.86; P = 0.008). In-hospital mortality of the very elderly was 11 out of 45 compared with 8 per cent (20 of 247) in the younger group. Fatal outcome was more often caused by medical (seven) than by surgical complications (four cases). The remaining 34 patients recovered well. Very elderly patients undergoing esophagectomy have no elevated risk for occurrence of surgical complications, whereas the mortality of these complications is much higher. Improved outcome is achievable by timely management of postoperative surgical as well as medical complications. Notwithstanding the increased mortality, esophagectomy should be considered in thoroughly selected very elderly patients with curable esophageal carcinoma.

Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis

Background

Current evidence on the benefits of different anastomotic techniques (hand‐sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes.

Methods

This was a systematic review and network meta‐analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non‐randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta‐analysis of postoperative anastomotic leaks and strictures was performed.

Results

Of 4192 articles screened, 15 randomized and 22 non‐randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001).

Conclusion

LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.

A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) is a demanding surgical procedure, thus explaining its slow expansion and limited popularity amongst Hepato-Pancreatico-Biliary (HPB) surgeons. However, three main advantages of robotic assisted pancreaticoduodenectomy (PD) including improved dexterity, 3D vision less surgical fatigue, may overcome some of the hurdles and ultimately lead to a wider adoption. This systematic review and network meta-analysis aims to evaluate the current literature on open and MIPD.

METHODS

A systematic literature search was conducted for studies reporting robotic, laparoscopic and open surgery for PD. Network meta-analysis of intraoperative (operating time, blood loss, transfusion rate), postoperative (overall and major complications, pancreatic fistula, delayed gastric emptying, length of hospital stay) and oncological outcomes (R0 resection, lymphadenectomy) were performed.

RESULTS

Sixty-one studies including 62,529 patients were included in the network meta-analysis, of which 3% (n = 2131) were totally robotic (TR) and 10% (n = 6514) were totally laparoscopic (TL). There were no significant differences between surgical techniques for major complications, overall and grade B/C fistula, biliary leak, mortality and R0 resections. Transfusion rates were significantly lower in TR compared to TL and open. Operative time for TR was longer compared with open and TL. Both TL and TR were associated with significantly lower rates of wound infections, pulmonary complications, shorter length of stay and higher lymph nodes examined when compared to open. TR was associated with significantly lower conversion rates than TL.

CONCLUSION

In summary, this network meta-analysis highlights the variability in techniques within MIPD and compares other variations to the conventional open PD. Current evidence appears to demonstrate MIPD, both laparoscopic and robotic techniques are associated with improved rates of surgical site infections, pulmonary complications, and a shorter hospital stay, with no compromise in oncological outcomes for cancer resections.

Surveillance or resection after chemoradiation in esophageal cancer

The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery. Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.

Analysis of Predictors for Lymph Node Metastasis in Patients with Superficial Esophageal Carcinoma

In order to predict related risk factors for lymph node metastasis (LNM) in patients with superficial esophageal carcinoma (SEC) and provide reference for endoscopic minimally invasive treatment, we included a total of 93 patients with superficial esophageal carcinoma who have underwent esophagectomy and lymph node dissection from 2010 to 2015. The depth of invasion was remeasured and classified into 6 groups according to their wall penetration. The prediction model was founded based on the independent risk factors. The results shows that lymph node metastasis of m1, m2, m3, sm1, sm2, and sm3 of superficial esophageal carcinoma was 0%, 0%, 5.3%, 8.7%, 17.6%, and 37.5%, respectively. The tumor size, differentiation, and lymphvascular invasion were also significantly related to lymph node metastasis by univariate analysis. Multivariate analysis showed that the depth of invasion and lymphovascular invasion were independent risk factors of lymph node metastasis. A prediction model for lymph node metastasis was established as follows: p = e^x/(1 + e^x), and x = −5.469 + 0.839 × depth of invasion + 1.992 × lymphavascular metastasis. The area under ROC curve was 0.858 (95% CI: 0.757–0.959). It was also shown that the depth of invasion was related to tumor differentiation, macroscopic type, and tumor size.

Thoracolaparoscopic dissection of esophageal lymph nodes without esophagectomy is feasible in human cadavers and safe in a porcine survival study

High-risk early esophageal adenocarcinoma (i.e. submucosal invasion >500 nm, poor differentiation, and/or presence of lymphovascular invasion) is currently treated with esophagectomy with lymph node (LN) dissection given the high rates of LN metastases. However, esophagectomy is associated with substantial morbidity and mortality. Endoscopic radical resection followed by thoracolaparoscopic LN dissection without concomitant esophagectomy could be an alternative. The study aim was to evaluate the feasibility and safety of thoracolaparoscopic dissection of esophageal LNs in a preclinical setting. (i) In human cadavers, thoracolaparoscopic dissection of LNs involved in drainage of the esophagus was performed. Subsequently, esophagectomy was performed to be able to detect retained LNs. Outcome parameters included the number of dissected LNs, the number of retained LNs in the esophagectomy specimen (ES), and technical success. (ii) In swine, thoracolaparoscopic LN dissection was also performed. After the procedure, the swine survived for 28 days. Thereafter, the swine were sacrificed and esophagectomy was performed. Outcome parameters included the presence of ischemia and/or stenosis in the ES and other complications. (i) In five human cadavers, a median of 26 LNs (interquartile range 22-46) were dissected. In two ES, one retained LN was found: one high paraesophageal, one low paraesophageal. Technical success rate was 100%. (ii) None of the seven porcine ES showed signs of ischemia or stenosis. One swine died because of ventricular fibrillation during surgery; during follow up no complications were observed. Thoracolaparoscopic dissection of LNs involved in the drainage of the esophagus is feasible in human cadavers and swine. The porcine survival study suggests that the esophageal vascularity is not severely compromised by the procedure. As anatomy differs between swine and humans, safety of the procedure will have to be investigated thoroughly before applying this new technique as the treatment of choice.

Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease

BACKGROUND

Esophagectomy for submucosal (T1b) esophageal adenocarcinoma (EAC) is performed in order to optimize patient outcomes given the risk of concurrent lymph node metastases (LNM). However, not seldom, comorbidity precludes these patients from surgery. Therefore, the aim of our study was to assess the course of follow-up after treatment in submucosal EAC patients undergoing surgery versus conservative therapy and to evaluate the incidence of metastatic disease.

METHODS

Between 2001 and 2012, all patients undergoing diagnostic endoscopic resection for EAC in two centers were reviewed. Only patients with histopathologically proven submucosal tumor invasion were included. Submucosal EACs were divided into tumors that were removed radically (R0) and irradically (R1). Subsequently, in the R0 group, EACs were classified as either low risk (LR; submucosal invasion <500 nm, G1-G2, no LVI) or high risk (HR; deep submucosal invasion >500 nm, G3-G4 and/or LVI). Metastatic disease was defined as LNM in surgical resection specimen and/or evidence of malignant disease during follow-up (FU).

RESULTS

Sixty-nine patients with a submucosal EAC were included [23 R1-resections and 46 R0-resection (14 R0-LR and 32 R0-HR)]. Twenty-six patients underwent surgical treatment (1 R0-LR, 12 R0-HR and 13 R1). None of the 14 R0-LR patients developed metastatic disease after a median FU of 60 months. In the R0-HR group and R1 group, metastatic disease was diagnosed in 16 and 30 % of patients, respectively. Surgical patients tended to have a better overall survival than non-surgical patients (p = 0.09). Tumor-related deaths, however, were 12 % in both groups.

CONCLUSIONS

In LR submucosal EAC, the risk of metastatic disease appears to be very low. In deep submucosal EAC (either R0- or R1-resection), the rate of metastatic disease is lower than reported in earlier surgical series. Given the reasonable disease-free survival and high background mortality, conservative management of these patients seems to be a valid alternative for surgery in selected cases.

Surgical Method, Postoperative Complications, and Gastrointestinal Motility of Thoraco-Laparoscopy 3-Field Esophagectomy in Treatment of Esophageal Cancer

Background

The aim of this study was to investigate the surgical method, postoperative complications, and gastrointestinal motility of thoraco-laparoscopic esophagectomy in the treatment of esophageal cancer.

Material/Methods

Using random sampling method, we selected 132 esophageal cancer patients who were treated in our hospital from January 2012 to December 2014; these patients were regarded as the study group and underwent thoraco-laparoscopy 3-field surgery treatment. Another 108 esophageal cancer patients admitted to our hospital over the same period were regarded as the control group and underwent traditional open McKeown esophagectomy.

Results

The amount of blood loss and postoperative drainage of pleural fluid in the study group were significantly lower (P<0.05) and the time to removal of the chest tube and hospital stay were significantly shorter (P<0.05). The incidence of anastomotic fistula, vocal cord paralysis, chylothorax, and arrhythmia were significantly lower in the study group than in the control group (P<0.05). However, no significant differences in the incidence of pneumonia, atelectasis, or acute respiratory distress were detected (P>0.05). For postoperative gastrointestinal motility, first flatus time, first defecation time, and bowel tone recovery time after the operation, as well as the total amount of gastric juice draining, were reduced in the thoraco-laparoscopic esophagectomy group (P<0.05). The postoperative MTL and NO levels were higher but VIP level was lower in the thoraco-laparoscopic group (P<0.05).

Conclusions

Thoraco-laparoscopic esophagectomy was technically feasible and safe; it was associated with lower incidence of certain postoperative complications and had less effect on postoperative gastrointestinal motility. Skilled technique and cooperation could further shorten the operation time and might lead to better patient outcomes.

Patient Selection for Oesophagectomy: Impact of Age and Comorbidities on Outcome

INTRODUCTION

Surgical resection of oesophageal cancer is a major procedure with potential for significant morbidity and mortality. Patient selection can be challenging, as operative benefit must be balanced against risk and impact on quality of life. This study defines modern trends in patient selection, and evaluates the impact of age, stage, and comorbidities on complications and survival following oesophagectomy, in a tertiary Australian experience.

METHODS

Data were compiled across two 15-year operative eras ('Era 1': 1981-1995; and 'Era 2': 1996-2010), with patients followed minimum 3 years. A total of 180 unselected records were analysed (powered for a relative hazard ratio of 0.5). Analyses defined patient selection trends, and for Era 2, the impact of age, comorbidities (Charlson score), and disease (T/N stage) on complications (Clavien-Dindo grade) and survival (Kaplan-Meier). A further sub-analysis was conducted with data divided into three 10-year periods.

RESULTS

The age of operated patients increased from Era 1 to 2 (mean+5 years; P<0.001), but survival and complication rates were unchanged, including in patients≥75 years (P>0.5). In Era 2, reflecting recent practice, survival duration matched T/N stage (P<0.001) but was independent of age at surgery (P=0.56) and comorbidity score (P=0.78). However, grade of worst post-operative complication, including death (rate: 3.8%), was correlated with both age (P<0.01) and comorbidity score (P<0.01).

DISCUSSION

Older patients are now undergoing oesophagectomy. However, if they are selected appropriately, then older patients and those with comorbidities can expect similar stage-matched survival outcomes to younger fitter patients, despite their higher operative risk. Poor outcomes persist in patients with locally advanced disease, and selection in this group should prioritise quality of life.

Salvage Surgery After Chemoradiotherapy in the Management of Esophageal Cancer: Is It a Viable Therapeutic Option?

PURPOSE

The aim of this large multicenter study was to assess the impact of salvage esophagectomy after definitive chemoradiotherapy (SALV) on clinical outcome.

PATIENTS AND METHODS

Data from consecutive adult patients undergoing resection for esophageal cancer in 30 European centers from 2000 to 2010 were collected. First, groups undergoing SALV (n = 308) and neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS; n = 540) were compared. Second, patients who benefited from SALV for persistent (n = 234) versus recurrent disease (n = 74) were compared. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics.

RESULTS

SALV versus NCRS groups: In-hospital mortality was similar in both groups (8.4% v 9.3%). The only significant differences in complications were seen for anastomotic leak (17.2% v 10.7%; P = .007) and surgical site infection, which were both more frequent in the SALV group. At 3 years, groups had similar overall (43.3% v 40.1%; P = .542) and disease-free survival (39.2% v 32.8%; P = .232) after matching, along with a similar recurrence pattern. Persistent versus recurrent disease groups: There were no significant differences between groups in incidence of in-hospital mortality or major complications. At 3 years, overall (40.9% v 56.2%; P = .046) and disease-free survival (36.6% v 51.6%; P = .095) were lower in the persistent disease group.

CONCLUSION

The results of this large multicenter study from the modern era suggest that SALV can offer acceptable short- and long-term outcomes in selected patients at experienced centers. Persistent cancer after definitive chemoradiotherapy seems to be more biologically aggressive, with poorer survival compared with recurrent cancer.

Long-term quality of life and alimentary satisfaction after esophagectomy with colon interposition

BACKGROUND

The long-term outcome after colon interposition for esophageal reconstruction is not well documented. Our objective was to assess quality of life and alimentary satisfaction 10 or more years after colon interposition.

METHODS

Patients who had an esophagectomy that was reconstructed using a colon interposition before April 2003 were identified. Symptoms, alimentary satisfaction, and quality of life were assessed by telephone interview and questionnaires.

RESULTS

We identified 79 surviving patients, and follow-up was obtained in 63 (80%). The indication for esophagectomy was cancer in 45 patients and benign disease in 18. Vagal-sparing esophagectomy was performed in 48% of patients, en bloc in 44%, and transhiatal in 8%. Median follow-up was 13 years (range, 10 to 38 years). The median Gastrointestinal Quality of Life Index score was 3 of 4 and results from the RAND 36-Item Short Form Health Survey (RAND Corp, Santa Monica, CA) were at or above the published normal means in all categories. Most patients were free of dysphagia (89%), regurgitation (84%), and heartburn (84%). The most common postprandial symptom was early satiety (40%). The body mass index was within normal reference ranges in 90% of patients. Follow-up esophagogastroduodenoscopy in 30 patients at a median of 6 years showed no Barrett's metaplasia in the residual esophagus. Seven patients had a reoperation for colon redundancy.

CONCLUSIONS

Long-term alimentary satisfaction and quality of life were excellent after colon interposition. Most patients were free of dysphagia and few needed revision for redundancy. These results should encourage the use of a colon interposition in patients expected to survive long-term after esophagectomy.

Meta-analysis shows clinically relevant and long-lasting deterioration in health-related quality of life after esophageal cancer surgery

PURPOSE

The purpose of the study is to (1) estimate the direction, clinical relevance, and duration of health-related quality-of-life (HRQL) change in the first year following esophageal cancer surgery and (2) to assess the robustness of the estimates by subgroup and sensitivity analyses, and an exploration of publication bias.

METHODS

A systematic literature search in MEDLINE, EMBASE, CINAHL, PsychINFO, and CENTRAL to identify randomized and non-randomized studies was performed. We compared the baseline HRQL data with 3-, 6-, 9-, or 12-month follow-ups to estimate the magnitude and duration of HRQL change. These estimates were then classified as trivial, small, medium, or large. Primary outcomes were role functioning, eating, and fatigue. Secondary outcomes were physical and social functioning, dysphagia, pain, and coughing problems. We conducted subgroup analysis for open surgery, open surgery preceded by neoadjuvant therapy, and minimally invasive surgery. Sensitivity analyses assessed the influence of study design, transformation/imputation of the data, and HRQL questionnaire used.

RESULTS

We included the data from 15 studies to estimate the change in 28 HRQL outcomes after esophageal cancer surgery. The main analysis showed that patients' social functioning deteriorated. Symptoms of fatigue, pain, and coughing problems increased. These changes lasted for 9-12 months, although some symptoms persisted beyond the first year after surgery. For many other HRQL outcomes, estimates were only robust after subgroup or sensitivity analyses (e.g., role and physical functioning), or remained too heterogeneous to interpret (e.g., eating and dysphagia).

CONCLUSIONS

Patients will experience a clinically relevant and long-lasting deterioration in HRQL after esophageal cancer surgery. However, for many HRQL outcomes, more and better quality evidence is needed.

A single surgeon's series of transthoracic oesophageal resections

INTRODUCTION

Significant controversy persists over the optimum surgical management of oesophageal carcinoma. The authors report on a consecutive personal series of open transthoracic oesophageal resections.

METHODS

Data relating to resections performed between mid-1993 and the end of 2010 were analysed. Patient and tumour assessment evolved over this period. Preoperative chemotherapy in appropriate cases was introduced in 2002. A laparotomy and right lateral thoracotomy approach (Ivor-Lewis) was used. In all cases the pylorus was not interfered with, no attempt was made to perform a radical lymphadenectomy but surgical strategy was focused on producing an R0 resection and a hand sewn anastomosis was fashioned.

RESULTS

A total of 165 resections were performed; 130 patients (80%) were male. The median age was 66 years (range: 31-82 years). Eighty per cent had an adenocarcinoma. Sixty-four per cent of the tumours were T3/T4 and sixty-two per cent node positive. Forty patients (24%) had an involved circumferential resection margin (CRM). Five patients (3.0%) had no resection and a quarter (26%) developed morbidity of some form. There was one clinical anastomotic leak (0.6%) and three benign strictures requiring dilation (1.8%). In-hospital mortality was 3.0% (5 patients). Disease specific survival at one, two and five years was 77%, 42% and 36% respectively. Neither CRM involvement nor preoperative chemotherapy influenced survival significantly. No patient required intervention to disrupt the pylorus.

CONCLUSIONS

Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.

Assessment of short-term clinical outcomes following salvage esophagectomy for the treatment of esophageal malignancy: systematic review and pooled analysis

BACKGROUND

Combined chemoradiotherapy is increasingly being used as definitive treatment for locoregional esophageal malignancy. Patients with residual or recurrent localized cancer are often selectively considered for salvage esophagectomy (SALV). The aim of this pooled analysis was to compare short-term clinical outcomes from SALV following definitive chemoradiotherapy with those from planned esophagectomy following neoadjuvant chemoradiotherapy (NCRS).

METHODS

MEDLINE, EMBASE, Cochrane, trial registries, conference proceedings and reference lists were searched for relevant comparative studies. Primary outcome measures were in-hospital mortality, anastomotic leak and pulmonary complications. Secondary outcomes were length of hospital stay, negative (R0) resection margin, and estimated blood loss.

RESULTS

Eight studies comprising 954 patients; 242 (SALV) and 712 (NCRS) were included. SALV was associated with a significantly increased incidence of post-operative mortality (9.50 vs. 4.07 %; pooled odds ratio [POR] = 3.02; p < 0.001), anastomotic leak (23.97 vs. 14.47 %; POR = 1.99; p = 0.005), pulmonary complications (29.75 vs. 16.99 %; POR = 2.12; p < 0.001), and an increased length of hospital stay (weighted mean difference = 8.29 days; 95 % CI 7.08-9.5; p < 0.001). There were no significant differences between the groups in the incidence of negative resection margins or estimated blood loss.

CONCLUSIONS

SALV has poorer short-term outcomes when compared with planned esophagectomy following neoadjuvant chemoradiotherapy. Patients and multidisciplinary tumor boards should be made aware of these differences in outcomes and SALV should be reserved for practice in high-volume institutions.

Meta-analysis shows clinically relevant and long-lasting deterioration in health-related quality of life after esophageal cancer surgery

PURPOSE

The purpose of the study is to (1) estimate the direction, clinical relevance, and duration of health-related quality of life (HRQL) change in the first year following esophageal cancer surgery and (2) to assess the robustness of the estimates by subgroup and sensitivity analyses, and an exploration of publication bias.

METHODS

A systematic literature search in MEDLINE, EMBASE, CINAHL, PsychINFO, and CENTRAL to identify randomized and non-randomized studies was performed. We compared the baseline HRQL data with 3-, 6-, 9-, or 12-month follow-ups to estimate the magnitude and duration of HRQL change. These estimates were then classified as trivial, small, medium, or large. Primary outcomes were role functioning, eating, and fatigue. Secondary outcomes were physical and social functioning, dysphagia, pain, and coughing problems. We conducted subgroup analysis for open surgery, open surgery preceded by neo-adjuvant therapy, and minimally invasive surgery. Sensitivity analyses assessed the influence of study design, transformation/imputation of the data, and HRQL questionnaire used.

RESULTS

We included data from 15 studies to estimate the change in 28 HRQL outcomes after esophageal cancer surgery. The main analysis showed that patients' social functioning deteriorated. Symptoms of fatigue, pain, and coughing problems increased. These changes lasted for 9-12 months, although some symptoms persisted beyond the first year after surgery. For many other HRQL outcomes, estimates were only robust after subgroup or sensitivity analyses (e.g., role and physical functioning), or remained too heterogeneous to interpret (e.g., eating and dysphagia).

CONCLUSIONS

Patients will experience a clinically relevant and long-lasting deterioration in HRQL after esophageal cancer surgery. However, for many HRQL outcomes, more and better quality evidence is needed.