Complications of esophagectomy

GI and GU fluoroscopy in common post-op oncologic surgeries: what you need to know about this leaky business!

Over the past several years, there has been a trend of decreasing screening or diagnostic fluoroscopic examinations ordered by clinical teams, particularly double contrast gastrointestinal studies. The underlying reason is due to increasing number of endoscopic procedures performed by Gastroenterology and Urology and usage of other imaging modalities, which are either more sensitive and/or offer the ability to obtain tissue for confirmation. Many fluoroscopic studies are now tailored toward patients who have undergone gastrointestinal or genitourinary oncologic surgeries, providing both functional and anatomic information, which are important tools for patient management. Some of these surgeries are very complex and an understanding of the postoperative anatomy and potential pitfalls is important to accurately evaluate for complications. The purpose of this article is to describe techniques and indications for common post-operative fluoroscopic procedures in gastrointestinal and genitourinary oncology while reviewing normal appearances. Complications, with emphasis on postoperative leaks, will be highlighted. Familiarity with the various types of gastrointestinal surgeries and urinary diversion techniques and knowledge of the expected postsurgical appearance is essential for achieving an accurate and prompt diagnosis of complications to allow for adequate treatment and management.

Perioperative corticosteroids for reducing postoperative complications following esophagectomy: an updated systematic review and meta-analysis

BACKGROUND

This updated systematic review and meta-analysis aims to evaluate the efficacy and safety of perioperative corticosteroid administration versus placebo for esophageal cancer patients following scheduled esophagectomy.

METHODS

We searched databases through June 30, 2023. We included articles on randomized controlled trials (RCTs) comparing perioperative corticosteroid administration with placebo in esophageal cancer patients with esophagectomy. The outcomes were the death rate during hospitalization, length of hospital stay, and short-term complications. Risk ratios (RRs) and corresponding 95% confidence interval (CIs) for each estimated effect size were applied for dichotomous outcomes, and the mean difference (MD) and corresponding 95% CIs for each estimated effect size were applied for continuous outcomes. We used GRADE to evaluate the quality of each of the outcome and the level of recommendations.

RESULTS

Nine RCTs with 508 participants were included in this study. Severe outcomes, including the length of hospital stay, leakage, mortality during the hospitalization period in the corticosteroid group was comparable to that in the control group, but positive effects of corticosteroid administration were observed on the length of intensive care unit stay (MD -3.1, 95% CI - 5.43 to - 0.77), cardiovascular disorders (RR 0.44, 95% CI 0.21-0.94) and other general complications (RR 0.49, 95% CI 0.29-0.85).

CONCLUSIONS

Peri-operative intravenous corticosteroid administration may reduce cardiovascular disorders, other general complications and the length of ICU stay without carrying severe outcomes. More high quality RCTs are warranted to further investigate the effects of corticosteroids on postoperative mortality and complications for esophageal cancer patients with esophagectomy.

SYSTEMATIC REVIEW REGISTRATION

Cochrane, registration number: 196.

Planned oesophagectomy after chemoradiotherapy versus salvage oesophagectomy following definitive chemoradiotherapy: a systematic review and meta-analysis

BACKGROUND

Oesophageal cancer is the eighth most common cancer and sixth leading cause of cancer-related mortality worldwide. Salvage oesophagectomies are associated with an increased risk of mortality, although recent data suggests that long-term survival rates following salvage oesophagectomy are similar to planned oesophagectomy. The aim was therefore to meta-analyse outcomes for patients undergoing salvage versus planned oesophagectomies to assess the differences in short-term mortality and long-term survival.

METHODS

A systematic review of Medline, Scopus, Web of Science and PubMed was performed to identify relevant studies. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.

RESULTS

Nineteen studies meeting inclusion criteria were included in the meta-analysis, which compared patients in the planned oesophagectomy group (n = 23 555) to patients in the salvage oesophagectomy group (n = 2227). There were significant differences between the groups in terms of rates of postoperative mortality (5.7% salvage oesophagectomy versus 3.1% planned oesophagectomy, P = 0.0004), anastomotic leak (20.6% salvage oesophagectomy versus 14.5% planned oesophagectomy, P < 0.00001), pulmonary complications (37.1% salvage oesophagectomy versus 24.2% planned oesophagectomy, P < 0.0001) and R0 margin (87.6% salvage oesophagectomy versus 91.3% planned oesophagectomy, P < 0.0001). There was no statistical difference between long-term survival rates at 5 years with 39.2% for salvage and 42.6% for planned oesophagectomy (P = 0.28).

CONCLUSIONS

Salvage oesophagectomies do offer a meaningful chance of long-term survival (at 5 years) for select patients with oesophageal cancer, but the elevated risk of post-operative complications and mortality following salvage oesophagectomy should be recognized.

Clinical comparative study of glasses-free 3D and 2D thoracoscopic surgery in minimally invasive esophagectomy

Objective

To investigate the safety and efficacy of glasses-free three-dimensional (3D) thoracoscopic surgery in minimally invasive esophagectomy (MIE).

Methods

The clinical data of 98 patients, including 81 men and 17 women aged 45–77 years, with esophageal squamous cell carcinoma who underwent minimally invasive thoracoscopic esophagectomy from January 2017 to December 2019 [3 years, with clinical follow-up time: 1 year~4 years (2017.01–2020.12)] were retrospectively analyzed. Patients were divided into two groups according to different surgical methods including a glasses-free 3D thoracoscopic group (G-3D group: 38 patients) and a two-dimesional (2D) thoracoscopic group (2D group: 60 patients). The clinical outcome of the two groups were compared.

Results

The operation time of the thoracoscopic part in the G-3D group was significantly shorter than that in the 2D group (P<0.05). The total number of lymph node dissection in the G-3D group was more than that in the 2D group (P<0.05). The thoracic indwelling time, postoperative hospital stay, severe pulmonary infection, arrhythmia, anastomotic leakage, chylothorax, and recurrent laryngeal nerve injury were not significantly different between the two groups (P>0.05). There was also no significant difference between the two groups on the progression-free survival (P>0.05).

Conclusion

Glasses-free 3D thoracoscopic surgery for esophageal cancer is a safe and effective surgical procedure. Compared with 2D thoracoscopic MIE, glasses-free 3D thoracoscopic MIE for esophageal cancer has higher safety, more lymph node dissection, and higher operation efficiency through the optimized surgical operations. We believe that glasses-free 3D thoracoscopy for MIE is worthy of clinical promotion.

Treatment paradigms and survival outcomes in esophageal adenocarcinoma with liver metastasis: a retrospective cohort study using the SEER database

Background

Esophageal adenocarcinoma with liver metastasis (EACLM) at the time of diagnosis has a poor prognosis and few therapeutic options. The best treatment options and prognostic factors for EACLM patients are unclear. The present study sought to explore the optimal treatment modalities for and the prognosis of these patients.

Methods

Patients diagnosed with EACLM at the time of diagnosis were identified from the Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2015. The last follow-up date was December 31, 2018. Treatment patterns were divided into four groups: local therapy (surgery/radiation), systemic therapy [chemotherapy (CT)], combination therapy (surgery/radiation + CT), and no treatment. The Kaplan-Meier (K-M) method and log-rank test were used for overall survival (OS) and disease-specific survival (DSS). Univariable and multivariable Cox regression were performed to identify the prognostic factors. Propensity score-matching (PSM) analyses were performed for sensitive analyses.

Results

A total of 925 patients diagnosed with EACLM were included in the study. The median OS was 12, 10, 3, and 2 months for combination therapy, systemic therapy, local therapy, and no treatment, respectively (P<0.001). After PSM, the patients who received systemic treatment had a better OS (median 9 vs. 2 months; P<0.001) and DSS (median 9 vs. 3 months; P<0.001) than those who received no treatment. Compared to systemic therapy, combination therapy did not increase patients' OS (median 13 vs. 12 months, P=0.069) but did improve their DSS (median 19 vs. 13 months, P=0.048).

Conclusions

EACLM patients might benefit the most from systemic therapy and combination therapy. For patients who are well-tolerated, combination therapy should be considered as a preferable option.

Endoscopic Submucosal Dissection Versus Radical Surgery for T1 Superficial Esophageal Cell Carcinoma: a Subgroup Survival Analysis

BACKGROUND

With the continuous advent of magnifying endoscopy, endoscopic submucosal dissection (ESD) has gradually become the mainstream treatment for early esophageal cancer. We aimed to compare the outcomes of patients with T1 superficial esophageal cell carcinoma treated with ESD vs. esophagectomy.

METHODS

We retrospectively analyzed patients who underwent ESD or radical surgery at the First Affiliated Hospital of Nanchang University from January 1, 2010, to December 31, 2018. The purpose of propensity score matching is to reduce selection bias. Precise subgroup analysis according to depth of invasion was performed to reduce the influence of confounding factors.

RESULT

We reviewed patients who underwent ESD (n = 117) or radical surgery (n = 217) at the First Affiliated Hospital of Nanchang University from 2010 to 2018. The OS rate and progression-free survival rate in the ESD group were better than those in the surgery group (OS, P = 0.002. PFS, P = 0.004). The ESD group had a lower early adverse event rate (74.6% vs. 91%, P = 0.012), shorter hospital stays (median 10 days vs. 18 days, P < 0.001), and lower hospitalization costs (median 15,455 vs. 62,376 RMB, P < 0.001). Multivariate Cox regression analysis found that the treatment method was an independent risk factor affecting the prognosis of patients with superficial esophageal cancer, and the death risk of patients in the ESD group was 0.377 times that of the radical surgery group (HR = 0.377, P = 0.023). We conducted a subgroup analysis of patients again according to the depth of invasion; 37 pairs of patients were included in the T1a stage, and 19 pairs of patients were included in the T1b stage. In T1a and T1b patients, the difference in OS rate and PFS rate between the two treatments was statistically significant (T1a, OS, P = 0.002, PFS, P = 0.004; T1b, OS, P = 0.019, PFS, P = 0.022), and the OS rates in the ESD group were better than those in the radical surgery group.

CONCLUSION

For patients with T1b superficial esophageal cancer, ESD has a longer overall survival and progression-free survival compared with radical surgery. These results support ESD as the preferred treatment for stage T1b superficial esophageal cancer.

Near-infrared fluorescent imaging with indocyanine green in rabbit and patient specimens of esophageal cancer

Background

We aimed to assess the possibility of detecting esophageal cancer after intravenous injection of indocyanine green (ICG) in preclinical and clinical models.

Methods

Forty-five rabbits were surgically implanted with VX2 tumors into the esophageal muscular layer 2 weeks before esophagectomy. The rabbits received intravenous injection of ICG at doses of 1, 2, or 5 mg/kg at 3, 6, 12, 24, or 48 h before surgical removal of esophagus. Twelve patients scheduled to undergo esophagectomy were also enrolled, and all received 2 mg/kg of ICG intravenously at 3, 6, 12, or 24 h before surgical removal of esophagus. The fluorescence intensity was measured in all resected specimens from the rabbits and patients using a near-infrared (NIR) fluorescence imaging system after surgery.

Results

Esophageal tumors were successfully established in all rabbits, and fluorescent signals were detected in all animal and patient specimens. Tumor-to-normal ratio (TNR) analysis showed that higher doses resulted in a greater TNR. Injection of at least 2 mg/kg of ICG was required for clear visualization of the tumor, and the TNR was highest at 12 h after injection. The TNR in patients was also highest at 12 h (P=0.0004), with 2 mg/kg of ICG. None of the patients had major complications following ICG injection.

Conclusions

NIR fluorescence imaging can be used to visualize esophageal cancer after systemic injection of ICG. ICG at 2 mg/kg at 12 h is optimal for tumor detection. However, since the clinical trials were conducted in a small number of patients, further studies are needed in larger populations.

Perioperative Outcomes After Combined Esophagectomy and Lung Resection

INTRODUCTION

The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.

METHODS

Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.

RESULTS

Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).

CONCLUSIONS

Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

An updated review of the TNM classification system for cancer of the oesophagus and its complications

Cancer of the esophagus is an aggressive cancer with high mortality. Because of the esophagus's lack of serosa and its peculiar lymphatic drainage, esophageal cancer is diagnosed in advanced stages. The eighth edition of the TNM (2017) aims to standardize care for esophageal cancer throughout the world; it includes not only patients treated with esophagectomy alone, but also those receiving neoadjuvant chemotherapy and/or radiotherapy. One new development in the eighth edition is that it establishes separate classifications for different time periods, with pathologic stage groups for prior to treatment (cTNM), after esophagectomy (pTNM), and after neoadjuvant therapy (ypTNM). The combined use of endoscopic ultrasound, CT, PET-CT, and MRI provides the greatest accuracy in determining the clinical stage, and these techniques are essential for planning treatment and for evaluating the response to neoadjuvant treatment. Esophagectomy continues to be the main treatment; it is also the elective gastrointestinal surgery that has the highest mortality, and it carries the risk of multiple complications, including anastomotic leaks, pulmonary complications, technical complications, and functional complications.

Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety

BACKGROUND

Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil.

METHODS

This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded.

RESULTS

Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax.

CONCLUSION

Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer

BACKGROUND

It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery.

METHODS

All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality.

RESULTS

A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798).

CONCLUSION

Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.

Comprehensive Comparison of Right and Left Recurrent Laryngeal Nerves in the Tracheoesophageal Groove

OBJECTIVE

A left-sided cervical approach to esophageal mobilization is considered safer given the perceived oblique path and more lateral orientation of the right recurrent laryngeal nerve (RLN) in the tracheoesophageal groove. Given the risk of recurrent laryngeal nerve, the current study investigated if there are differences in right and left RLN location in the tracheoesophageal groove.

METHODS

Right and left RLNs were carefully exposed in human cadavers. Comparison of location was determined at tracheal rings 2, 4, and 6 using 3 parameters: depth of the RLN from the anterior margin of the tracheal ring, lateral distance of the RLN from the posterior margin of the tracheal ring, and distance of the RLN to the anterior midline trachea following the curvature of the trachea. Statistical analysis was used to determine differences between the right and left sides.

RESULTS

Compared with the right RLN, the left RLN was slightly over 1 mm deeper at the second tracheal ring. Despite this trend, there was no significant difference in RLN location between individual sides or as an aggregate for any of the 3 parameters at tracheal rings 2, 4, or 6.

CONCLUSIONS

Careful characterization of RLN location precludes avoiding hoarseness, aphonia, and vocal cord paralysis. Counter to common surgical perception and educational beliefs, this study demonstrated that right and left RLN anatomical courses do not significantly differ along the trachea. Therefore, ensnarement on either side during a blind mobilization of the cervical esophagus is equally likely to occur.

Robot-Assisted Esophagectomy After Neoadjuvant Chemoradiation-Current Status and Future Prospects

Multimodality treatment with neoadjuvant chemoradiation followed by surgery has become the standard of care for esophageal cancer. In the recent years, there has been a shift in focus of surgical approach from open esophagectomy to minimally invasive esophagectomy. Robot-assisted esophagectomy is being performed more often in centers across the world. However, there is limited data on role of robot-assisted esophagectomy in patients who have received neoadjuvant chemoradiation. Initial reports have shown that integrating neoadjuvant therapy to robot-assisted esophagectomy is feasible and safe. With the growing popularity of robot-assisted surgery worldwide among both surgeons and patients, understanding the impact of neoadjuvant chemoradiation on the procedure and its oncological outcome seems worthwhile. In the present study, we present a review of available literature on the feasibility and safety of robot-assisted minimally invasive esophagectomy in esophageal cancer patients after neoadjuvant chemoradiation.

Pattern of subcarinal lymph node metastasis and dissection strategy for thoracic esophageal cancer

Background

This study aimed to assess the role of subcarinal lymph nodes in lymph node metastasis in thoracic esophageal squamous cell carcinoma (ESCC) and to investigate the adequate range of lymph node dissection during esophagectomy.

Methods

This study included 782 thoracic ESCC patients who underwent esophagectomy between July 2008 and December 2010. The metastatic rate of subcarinal lymph nodes and their influencing factors were investigated. The outcome of subcarinal lymph node dissection was assessed using the efficacy index (the incidence of metastasis to a lymph node station (%) multiplied by the 5-year survival rate (%) of patients with metastasis to that lymph node station and divided by 100). Additionally, postoperative complications were compared between the subcarinal lymph node resection and reservation groups.

Results

The metastatic rates of subcarinal lymph nodes in the upper, middle, and lower thoracic ESCC were 8.3% (4/48), 19.1% (79/414), and 16.2% (23/142), respectively (χ²=3.669, P>0.05) and in T1, T2, T3, and T4 tumors were 0% (0/71), 4% (4/100), 22.2% (85/383), and 34% (17/50), respectively (χ²=42.859, P<0.05). Tumor invasion and size were significantly correlated with metastasis. For upper thoracic ESCC with positive subcarinal lymph nodes, metastasis tendency was mainly to the lower mediastinum. In middle third esophageal cancer, after subcarinal lymph nodes were involved, metastasis to the lower mediastinal lymph nodes increased by nearly 50%, and bidirectional metastasis increased by nearly three times compared with that before involvement. For lower third cancer with positive subcarinal lymph nodes, metastasis tendency was mainly to the upper mediastinum. The postoperative complication rates in the resection and reservation groups were as follows: overall, 19% and 14.6%, respectively (P>0.05), and pulmonary, 10.3% and 7.3%, respectively (P>0.05). The efficacy indexes of lymph node dissection at the upper, middle, and lower third esophagus were 0%, 7.6%, and 27.5%, respectively.

Conclusions

Dissection of subcarinal lymph nodes, which does not increase postoperative complications, should be performed routinely in lower thoracic ESCC after submucosal invasion of tumor; meanwhile, tumors larger than 3cm should also result in subcarinal lymph node dissection in patients with a tumor located in the upper esophagus and T1-T2 ESCC.

National trends and perioperative outcomes of robotic oesophagectomy following induction chemoradiation therapy: a National Cancer Database propensity-matched analysis

OBJECTIVES

Oesophagectomy following induction chemoradiation therapy (CRT) is technically challenging. To date, little data exist to describe the feasibility of a robotic approach in this setting. In this study, we assessed national trends and outcomes of robotic oesophagectomy following induction CRT compared to the traditional open approach.

METHODS

The National Cancer Database was queried for patients who underwent oesophagectomy following induction CRT (2010-2014). Trends of robotic utilization were assessed by a Mantel-Haenszel test of trend. Propensity matching controlled for differences in age, gender, comorbidity, stage, histology and tumour location between the robotic and open groups. Overall survival was estimated by Kaplan-Meier analysis and compared by a log-rank test.

RESULTS

Oesophagectomy following induction CRT was performed in 6958 patients. Of them, 555 patients (8%) underwent robotic surgery (5% converted to an open approach). Between 2010 and 2014, utilization of a robotic approach increased from 3% to 11% (Mantel-Haenszel, P < 0.001) and the number of hospitals performing at least 1 robotic oesophagectomy increased from 23 to 57. Compared to the traditional open approach, robotic oesophagectomy was used more frequently at academic hospitals (76% vs 60%, P < 0.001), and in patients living in metropolitan areas (85% vs 77%, P < 0.001) and those living in the Midwest (41% vs 33%, P < 0.001). In the matched groups, a robotic approach was associated with shorter median hospital stay (9 vs 10 days, P = 0.004) and dissection of more lymph nodes (median, 16 vs 12, P < 0.001). However, there were no differences in rates of positive margin resection (5% for both groups, P = 0.95), 30-day readmissions (5% vs 7%, P = 0.18), 30-day mortality (2.5% vs 4%, P = 0.79), 90-day mortality (9% vs 8.5%, P = 0.89) or 5-year overall survival (42% vs 39%, P = 0.19) between patients undergoing robotic and open surgery, respectively.

CONCLUSIONS

Robotic oesophagectomy after induction CRT is feasible and associated with shorter hospitalization compared to an open approach, and does not compromise the adequacy of oncological resection, perioperative outcomes or long-term survival.

An updated review of the TNM classification system for cancer of the esophagus and its complications

Cancer of the esophagus is an aggressive cancer with high mortality. Because of the esophagus's lack of serosa and its peculiar lymphatic drainage, esophageal cancer is diagnosed in advanced stages. The eighth edition of the TNM (2017) aims to standardize care for esophageal cancer throughout the world; it includes not only patients treated with esophagectomy alone, but also those receiving neoadjuvant chemotherapy and/or radiotherapy. One new development in the eighth edition is that it establishes separate classifications for different time periods, with pathologic stage groups for prior to treatment (cTNM), after esophagectomy (pTNM), and after neoadjuvant therapy (ypTNM). The combined use of endoscopic ultrasound, CT, PET-CT, and MRI provides the greatest accuracy in determining the clinical stage, and these techniques are essential for planning treatment and for evaluating the response to neoadjuvant treatment. Esophagectomy continues to be the main treatment; it is also the elective gastrointestinal surgery that has the highest mortality, and it carries the risk of multiple complications, including anastomotic leaks, pulmonary complications, technical complications, and functional complications.

It's not always too late: a case for minimally invasive salvage esophagectomy

INTRODUCTION

Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE).

MATERIALS AND METHODS

Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival.

RESULTS

97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04).

CONCLUSION

Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

Management of anastomotic leaks after esophagectomy and gastric pull-up

Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient’s clinical status and the surgeon’s preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.

Surgical treatment of the severe thoracic gastrocutaneous fistula by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma: A case report

BACKGROUND

Thoracic anastomotic fistula (TAF) is a severe postoperative complication of oesophagectomy, and its occurrence coupled with a thoracic gastrocutaneous fistula (TGCF) and tracheostenosis is very unusual and may lead to a fatal consequence.

CASE PRESENTATION

We describe a case of an old female diagnosed with mid-oesophageal carcinoma, who presented with a TAF after oesophagectomy, which was healed by an effective treatment, while a severe TGCF and tracheostenosis appeared one month postoperation. The complications were detected by gastroscopy, barium oesophagogram and thoracic computed tomography (CT). Through surgical treatments, including pedicled muscle flap filling and thoracoplasty, and a correlated corrective procedure, the patient completely recovered and was discharged six months after the admission.

CONCLUSION

Treatment by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma can be a curative alternative for the severe thoracic gastrocutaneous fistula.

Reduction of oxidative stress a key for enhanced postoperative recovery with fewer complications in esophageal surgery patients: Randomized control trial to investigate therapeutic impact of anesthesia management and usefulness of simple blood test for prediction of high-risk patients

BACKGROUND

Oxidative stress may be an integral determinant of surgical stress severity. We examined whether the preoperative level of derivatives of reactive oxygen metabolites (d-ROMs), an oxidative stress biomarker based on total hydroperoxides in circulating blood, is predictive of increased risk of delayed recovery and complications after surgery, as well as the effects of anesthesia management on postoperative recovery in light of oxidative stress.

METHODS

Patients (American Society of Anesthesiologists physical status I-II) scheduled for a radical esophagectomy (n = 186) were randomly selected to receive inhalational sevoflurane (n = 94) or intravenous propofol (n = 92) anesthesia. Preoperative blood d-ROMs level, as well as pre-and postoperative plasma ferric-reducing ability, were analyzed to assess oxidative stress, with white blood cell (WBC) count, C-reactive protein (CRP) level, incidence of severe postoperative complications, and postoperative recovery process within 30 days after surgery also examined in a double-blind fashion.

RESULTS

Postoperative normalization of WBC and CRP was extended in patients with elevated preoperative d-ROMs [WBC versus d-ROMs: correlation coefficient (r) = 0.58 P < .001; CRP versus d-ROMs: r = 0.46 P < .001]. Receiver operating characteristics analysis of d-ROMs in relation to incidence of severe postoperative complications revealed an optimum d-ROMs threshold value of 410 UCarr and that patients with ≥410 UCarr had a greater risk of complications as compared to those with lower values (odds ratio = 4.7). Plasma ferric-reducing ability was decreased by 61 ± 185 mmol·l (P < .001) after surgery, demonstrating development of surgery-related oxidative stress, the magnitude of which was positively correlated with preoperative d-ROMs level (r = 0.16, P = .043). A comparison of the 2 anesthesia management protocols showed that patients who received propofol, an antioxidant anesthetic, had no postoperative decrease in ferric-reducing ability, lower incidence of severe postoperative complications (7 of 92 versus 18 of 94, P = .030, odds ratio = 0.35), and faster uneventful recovery time (WBC normalization days 7.1 ± 5.2 versus 13.6 ± 10.2, P < .001) as compared to those who received sevoflurane.

CONCLUSIONS

Elevated preoperative blood d-ROMs predicts greater intraoperative oxidative stress and increased postoperative complications with prolonged recovery, thus is useful for identifying high-risk patients for delayed and complicated surgical recovery. Reduction of oxidative stress is vital for enhanced recovery, with control by antioxidants such as propofol a possible solution.

Impact of postoperative complications on outcomes after oesophagectomy for cancer

BACKGROUND

To allocate healthcare resources optimally, complication-related quality initiatives should target complications that have the greatest overall impact on outcomes after surgery. The aim of this study was to identify the most clinically relevant complications after oesophagectomy for cancer in a nationwide cohort study.

METHODS

Consecutive patients who underwent oesophagectomy for cancer between January 2011 and December 2016 were identified from the Dutch Upper Gastrointestinal Cancer Audit. The adjusted population attributable fraction (PAF) was used to estimate the impact of specific postoperative complications on the clinical outcomes postoperative mortality, reoperation, prolonged hospital stay and readmission to hospital in the study population. The PAF represents the percentage reduction in the frequency of a given outcome (such as death) that would occur in a theoretical scenario where a specific complication (for example anastomotic leakage) was able to be prevented completely in the study population.

RESULTS

Some 4096 patients were analysed. Pulmonary complications and anastomotic leakage had the greatest overall impact on postoperative mortality (risk-adjusted PAF 44·1 and 30·4 per cent respectively), prolonged hospital stay (risk-adjusted PAF 31·4 and 30·9 per cent) and readmission to hospital (risk-adjusted PAF 7·3 and 14·7 per cent). Anastomotic leakage had the greatest impact on reoperation (risk-adjusted PAF 47·1 per cent). In contrast, the impact of other complications on these outcomes was relatively small.

CONCLUSION

Reducing the incidence of pulmonary complications and anastomotic leakage may have the greatest clinical impact on outcomes after oesophagectomy.

Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study

BACKGROUND

Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus.

METHODS

A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment.

RESULTS

Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively).

CONCLUSION

We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.

Pulse oximetric assessment of anatomical vascular contribution to tissue perfusion in the gastric conduit

BACKGROUND

Tubularized stomach is a common substitute used after oesophageal resection. The risk for gastric conduit ischemia, as well as the mechanisms and dynamics for the occurrence of deficient tissue perfusion during the critical construction of a gastric tube, is poorly understood.

METHODS

Twenty-nine patients that underwent oesophagectomy were studied with transmural pulse oximetry of different parts of the stomach, and at predefined preparatory steps during the construction of the gastric conduit.

RESULTS

After ligation of the left gastric artery (LGA), a reduction to 83.5% in tissue saturation was observed. Three patients (10.3%) had a sustained saturation despite ligation at this point. During final preparation of the gastric tube, and after stapling of the minor curvature, saturation fell to 76.5%. Saturation increased significantly to 80.0% 2 h after the stapling, just before construction of the anastomosis (P = 0.021). There was no association between the level of oxygen saturation and the risk of anastomotic dehiscence.

CONCLUSION

During gastric tube construction for oesophageal replacement, conduit perfusion, measured as oxygen saturation with pulse oximetry, decreases significantly. The main cause of this reduction seems to be ligation of the LGA and the final stapling of the gastric tube. Future studies are needed to establish the clinical implications of this finding.

Increased Variance in Oral and Gastric Microbiome Correlates With Esophagectomy Anastomotic Leak

BACKGROUND

Anastomotic leak after esophagectomy remains a significant source of morbidity and mortality. The gastrointestinal (GI) microbiome has been found to play a significant role in tumor oncogenesis and postoperative bowel anastomotic leak. We hypothesized that the GI microbiome could differentiate between esophageal cancer histologies and predict postoperative anastomotic leak.

METHODS

A prospective study of esophagectomy patients was performed from May 2013 to August 2014, with the collection of oral saliva, intraoperative esophageal and gastric mucosa, and samples of postoperative infections (neck swab or sputum). The presence and level for each bacterial probe as end points were used to analyze correlations with tumor histology, tumor stage, and presence of postoperative complications by unequal variances t tests for multiple comparisons and principal coordinate analysis.

RESULTS

Esophagectomy was successful in 55 of 66 patients who were enrolled. Among those, the diagnosis was adenocarcinoma in 44 (80%) squamous cell carcinoma in (13%), and benign disease in 4 (7%). The 30-day mortality was 1.8% (1 of 55). Complications included anastomotic leak requiring local drainage in 18% (10 of 55) and postoperative pneumonia in 2% (1 of 55). No correlation was noted between GI microbiome flora and tumor histology or tumor stage. A significant difference (p = 0.015) was found when the variance in bacterial composition between the preoperative oral flora was compared with intraoperative gastric flora in patients who had a leak but not in patients with pneumonia.

CONCLUSIONS

Patients with anastomotic leaks had increased variance in their preoperative oral and gastric flora. Microbiome analysis could help identify patients at higher risk for leak after esophagectomy.

The effects of the herbal medicine Daikenchuto (TJ-100) after esophageal cancer resection, open-label, randomized controlled trial

BACKGROUND

Daikenchuto (TJ-100), a traditional Japanese herbal medicine, is widely used in Japan. Its effects on gastrointestinal motility and microcirculation and its anti-inflammatory effect are known. The purpose of this prospective randomized controlled trial was to investigate the effect of TJ-100 after esophagectomy in esophageal cancer patients.

METHODS

Forty patients for whom subtotal esophageal resection for esophageal cancer was planned at our institute from March 2011 to August 2013 were enrolled and divided into two groups at the point of determination of the operation schedule after informed consent was obtained: a TJ-100 (15 g/day)-treated group (n = 20) and a control group (n = 20). The primary efficacy end-points were maintenance of the nutrition condition and the recovery of gastrointestinal function. The secondary efficacy end-points were the serum C-reactive protein (CRP) level and adrenomedullin level during the postoperative course, the incidence of postoperative complications, and the length of hospital stay after surgery.

RESULTS

We examined 39 patients because one patient in the TJ-100 group was judged as having unresectable cancer after surgery. The mean age of the TJ-100 group patients was significantly older than that of the control group patients.The rate of body weight decrease at postoperative day 21 was significantly suppressed in the TJ-100 group (3.6% vs. the control group: 7.0%, p = 0.014), but the serum albumin level was not significantly different between the groups. The recovery of gastrointestinal function regarding flatus, defecation, and oral intake showed no significant between-group differences, but postoperative bowel symptoms tended to be rare in the TJ-100 group. There was no significant between-group difference in the length of hospital stay after surgery. The serum CRP level at postoperative day 3 was 4.9 mg/dl in the TJ-100 group and 6.9 mg/dl in the control group, showing a tendency of a suppressed serum CRP level in the TJ-100 group (p = 0.126). The rate of increase in adrenomedullin tended to be high postoperatively, but there was no significant difference between the two groups.

CONCLUSIONS

TJ-100 treatment after esophageal cancer resection has the effects of prompting the recovery of gastrointestinal motility and minimizing body weight loss, and it might suppress the excess inflammatory reaction related to surgery.

Analysis of risk factors for post-operative complications and prognostic predictors of disease recurrence following definitive treatment of patients with esophageal cancer from two medical centers in Northwest China

Evaluating the clinicopathological features of patients receiving definitive treatment for esophageal cancer may facilitate the identification of patterns and factors associated with post-operative complications, and enable the development of a surveillance strategy for surviving patients at a higher risk of disease recurrence. In the present study, clinical data from 579 patients with esophageal cancer that underwent radical resection of esophagus were collected. These patients were admitted to two medical centers in Northwest China, and information regarding the presence or absence of basic chronic diseases and post-operative results were retrospectively analyzed. The level of selected stem cell markers, including aldehyde dehydrogenase 1, CD133, integrin subunit α 6, integrin subunit β 4 and T-cell factor-4, were determined in esophageal cancer tissue samples in order to determine whether these markers may be useful predictors of disease prognosis and recurrence. Post-operative complications in patients receiving radical resection of the esophagus included respiratory system complications, cardiovascular abnormalities and esophageal anastomotic fistulae. Diabetes, basic respiratory disease and lower pre-surgical serum albumin levels were observed to be individual risk factors associated with post-operative complications, including respiratory system complications of acute respiratory failure and pulmonary infection, cardiovascular abnormalities of atrial fibrillation and arrhythmia, as well as the development of esophageal anastomotic fistulae. Diagnosis of esophageal cancer at later stage was significantly correlated with anastomotic fistula. Molecular detection of stem cell markers for prognosis prediction was achieved by immunohistochemical and immunofluorescence staining assays. The results demonstrated that the presence of stem-like cells in cancer tissues was associated with poor disease prognosis and a high recurrence ratio. In conclusion, the results of the current study suggested that post-operative complications were more likely to occur in patients with diabetes, basic respiratory disease or lower serum albumin levels prior to surgery. Therefore, sufficient intensive peri-operative care, rigorous operative risk assessments, and the selection of the patients with early or mid-stage esophageal cancer, may decrease the risk of post-surgical complications in patients receiving radical resection of the esophagus. In addition, a high ratio of esophageal cancer stem-like cells was associated with cancer recurrence. These results suggest that an intensive surveillance strategy should be implemented in order to facilitate early detection of disease recurrence and improve the clinical management of these patients post-surgery.

Esophagectomy in Patients with Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome: A Viable Option

The objective of this study was to assess the outcomes for patients with human immunodeficiency virus (HIV) and acquired immune deficiency virus (AIDS) who had esophagectomy done for both benign and malignant conditions. A retrospective chart review of patients with HIV and AIDS undergoing esophagectomy at a rural referral hospital was done for the period of 2009-2014. Patient postoperative complications, outcomes, and follow-up data were charted. All procedures were done by a single lead surgeon. Nine patients met the study criteria, 7 of whom had esophageal cancer, and 2 with strictures. Four patients had received nutritional self-expanding metal stent preoperatively. The mean stent duration was 61 days. Three patients had been on antiretroviral therapy before surgery. Preoperative CD4 counts were available in 7 patients. Eight patients underwent a 3-field esophagectomy and 1 was unresectable. Seven of these patients had successful outcomes, with varying follow-up times. One patient died post procedure while in the hospital. Complications included stricture and anastomotic leak. Although HIV-positive patients face increased risk during surgical procedures, this status should not be a firm contraindication to surgery. Quality nutritional status, antiretroviral use, and overall CD4 count levels remain important parameters in considering surgical treatment for these patients. With careful patient evaluation and planning, esophagectomy in an HIV and AIDS setting is feasible with successful outcomes.

Esophagectomy and Gastric Pull-through Procedures: Surgical Techniques, Imaging Features, and Potential Complications

Esophagectomy takes the center stage in the curative treatment of local and local-regional esophageal cancer. It is a complex procedure with a high postoperative complication rate. When interpreting imaging studies, radiologists must understand the surgical techniques used and their potential complications. The most common surgical techniques are transthoracic esophagectomies, such as the Ivor Lewis and McKeown techniques, and transhiatal esophagectomy. Variations of these techniques include different choices of conduit (ie, stomach, colon, or jejunum) to serve in lieu of the resected esophagus. Postoperative imaging and accurate interpretation is vital in the aftercare of these patients. Chest radiographs, esophagrams, and computed tomographic images play an essential role in early identification of complications. Pulmonary complications and anastomotic leaks are the leading causes of postoperative morbidity and mortality secondary to esophagectomy. Other complications include technical and functional problems and delayed complications such as anastomotic strictures and disease recurrence. An esophagographic technique is described that is performed by using hand injection of contrast material into an indwelling nasogastric tube. Familiarity with the various types of esophagectomy and an understanding of possible complications are of utmost importance for radiologists and allow them to be key participants in the treatment of patients undergoing these complicated procedures.

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.

Application of Oesophagogastric Cervical Mechanical Anastomosis in Oesophagectomy for Cancer

We aimed to explore the safety and the feasibility of the application of digestive tract-specific circular anastomats in oesophagogastric cervical anastomosis after oesophagectomy for cancer. We retrospectively analysed the clinical data of 241 patients undergoing oesophagogastric cervical anastomosis using disposable circular staplings after oesophagectomy in the People's Hospital of Henan Province, from August 2009 to July 2012. A total of 240 patients were anastomosed successfully. One patient had a partially torn oesophagus and underwent repair because the wrong stapler size was used. No operative death occurred. Seven patients (2.9 %) had postoperative cervical anastomotic leakage but recovered after short-term conservative treatment, and three patients had obvious gastro-oesophageal reflux after eating. No intrathoracic anastomotic leakage or other anastomotic instrument-related complications occurred. During a median follow-up period of 13.8 months, no anastomotic stricture was found in each patient. The application of oesophagogastric cervical anastomosis using circular anastomat after oesophagectomy for cancer was safe and feasible.

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.

Right versus left transthoracic approach for lymph node-negative esophageal squamous cell carcinoma

Background

To compare the right and left transthoracic approach on the post-operative survival of patients with lymph node-negative esophageal squamous cell carcinoma.

Methods

Six hundred and ninety-five ESCC patients who underwent esophagectomy between 1990 and 2005 were retrospectively enrolled in the present study and were confirmed by histology to be of no lymph node metastasis. Those who had received neoadjuvant chemotherapy or radiotherapy were excluded from the study. Patients were divided into two groups, the left (n = 545) and right (n = 150) transthoracic groups. The follow-up duration ranged from 1 to 20 years with a mean of 7 years. Kaplan–Meier and univariate and multivariate Cox proportional hazards were used for analysis.

Results

3- and 5-year CSS rates were 62.0 % and 44.0 % in the left group, while the corresponding figures in the right group were 56.0 % and 40.0 %(P < 0.05). The overall survival for the two groups was significantly different (P = 0.045). Survival analyses were stratified by stages, which found that the favorable survival advantage was not present. When the survival curves were stratified by tumor locations, a significant difference was not revealed. Surgical approaches were regarded as one of the prognostic factors in the univariate analysis (P = 0.019). However, this significance could not be confirmed in multivariate Cox regression analysis (P = 0.193).

Conclusions

The left transthoracic approach is superior in some aspects to the right transthoracic approach regarding surgical and oncological outcomes in the treatment of lymph node negative ESCC.

Intrapyloric botulinum injection increases postoperative esophagectomy complications

BACKGROUND

Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy.

METHODS

We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both.

RESULTS

Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping.

CONCLUSIONS

Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.

Comparison of pyloric intervention strategies at the time of esophagectomy: is more better?

BACKGROUND

Controversy remains regarding the role of pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. We aimed to compare the effect of pyloric drainage strategies upon subsequent risk of complications suggestive of conduit distention, including aspiration and anastomotic leak.

METHODS

A retrospective study was conducted reviewing patients undergoing esophagectomy between January 2007 and April 2012. Prospectively collected data included baseline comorbidities, operative details, hospital course, and complications. Statistical comparisons were performed using analysis of variance for continuous variables and χ(2) testing for categorical variables.

RESULTS

There were 361 esophagectomies performed during the study period; 68 were excluded from analysis (for prior esophagogastric surgery or benign disease or both). Among 293 esophagectomies included, emptying procedures were performed as follows: 44 (15%), no drainage procedure; 197 (67%), pyloromyotomy/pyloroplasty; 8 (3%), dilation alone; 44 (15%), dilation plus onabotulinumtoxinA. Aspiration occurred more frequently when no pyloric intervention was performed (5 of 44 [11.4%] versus 6 of 249 [2.4%], p = 0.030). The incidences of anastomotic leak (18 [6.1%]) and gastric outlet obstruction (5 [1.7%]) were statistically similar among groups. Subgroup analysis demonstrated persistence of these findings when limiting the comparison to transthoracic esophagectomies. Major complications directly related to pyloroplasty/pyloromyotomy occurred in 2 patients (0.6%), including 1 death (0.3%).

CONCLUSIONS

These data suggest that omission of pyloric intervention at the index operation results in more frequent aspiration events. The combination of dilation plus onabotulinumtoxinA provided for a similar complication profile compared with surgical drainage. Future prospective comparisons are needed to evaluate these short-term effects of pyloric intervention as well as long-term sequelae such as dumping syndrome and bile reflux.

Factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy

Response enthusiasm to telephone follow-up is a precondition for obtaining exhaustive information; however, no study has yet examined this specific issue. This study aimed to investigate possible factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy and to propose corresponding countermeasures. A telephone follow-up was conducted on patients who underwent oesophagectomy. The possible factors influencing response enthusiasm grades were investigated by univariate and logistic regression analyses. The study enrolled 346 eligible patients. Univariate analysis showed that the tumour, nodes, metastasis (TNM) staging (P = 0.004); survival status (P < 0.001); survival time (P < 0.001); complications/co-morbidities (P = 0.001); and the relationship between the patient and his/her contact person (P < 0.001) were significantly different among the three groups. The first group of patients had high response enthusiasm, the second group had moderate response enthusiasm, and the third group had low response enthusiasm. Logistic regression analysis demonstrated that only the complications/co-morbidities [confidence interval (CI) = -2.310 to -0.665, P < 0.001] and dysphagia status (CI = 0.039-1.509, P = 0.039) were independent factors affecting the response enthusiasm grades. The primary therapeutic results and the current complications and co-morbidities, especially the dysphagia status, were important factors influencing response enthusiasm grades. Planning a follow-up schedule with proper health instructions could be crucial to the quality of follow-up.

Update on clinical impact, documentation, and management of complications associated with esophagectomy

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.