Relationship between preoperative assessment of organ function and postoperative morbidity in patients with oesophageal cancer

Predictive Value of Diffusion, Glucose Metabolism Parameters of PET/MR in Patients With Head and Neck Squamous Cell Carcinoma Treated With Chemoradiotherapy

Purpose: This study aims to evaluate the predictive value of the pretreatment, metabolic, and diffusion parameters of a primary tumor assessed with PET/MR on patient clinical outcomes.

Methods: Retrospective evaluation was performed using PET/MR image data sets acquired using the single tracer injection dual imaging of 68 histologically proven head and neck cancer patients 4 weeks before receiving definitive chemoradiotherapy (CRT). PET/MR was performed before the CRT and 12 weeks after the CRT for response evaluation. Image data (PET and MRI diffusion-weighted imaging [DWI]) was used to specify the maximum standard uptake value, the peak lean body mass corrected, SUV_max, the metabolic tumor volume, the total lesion glycolysis (SUV_max, SUL_peak, MTV, and TLG), and the mean apparent diffusion coefficient (ADC_mean) of the primary tumor. Based on the results of the therapeutic response evaluation, two patient subgroups were created: one with a viable tumor and another without. Metabolic and diffusion data, from the pretreatment PET/MR and the therapeutic response, were correlated using Spearman's correlation coefficient and Wilcoxon's test.

Results: After completing the CRT, a viable residual tumor was detected in 36/68 (53%) cases, and 32/68 (47%) patients showed complete remission. However, no significant correlation was found between the pretreatment parameter, ADC_mean (p = 0.88), and the therapeutic success. The PET parameters, SUV_max and SUL_peak, MTV, and TLG (p = 0.032, p = 0.01, p < 0.0001, p = 0.0004) were statistically significantly different between the two patient subgroups.

Conclusion: This study found that MRI-based (ADC_mean) data from FDG PET/MR pretreatment could not be used to predict therapeutic response although the PET parameters SUV_max, SUL_peak, MTV, and TLG proved to be more useful; thus, their inclusion in risk stratification may also be of additional value.

Prognostic Value of Metabolic Tumor Volume Measured by 18F-FDG PET/CT in Esophageal Cancer Patients

Objective: In this study, we aimed to explore prognostic importance of definition of preoperative metabolic tumor volume in esophageal cancer patients.

Methods: 22 patients who have histologically proven stage IIA-III esophageal cancer and underwent ¹⁸F-FDG PET/CT for preoperative staging of disease were included to the study. After ¹⁸F-FDG PET/CT, all the patients underwent surgery within 4 weeks period. Patients have been followed up until death or Sept 15^th, 2012. Dates of death were recorded for survival analysis. During evaluation of ¹⁸F-FDG PET/CT images, metabolic tumor volumes were calculated by drawing the isocontour region of interests from all visually positive FGD uptake lesions.

Results: 22 patients (15M, 7F; mean age: 65.1±8.4, min-max:48-80) underwent ¹⁸F-FDG PET/CT for preoperative staging of esophageal cancer. Preoperative diagnosis was squamous cell and adeno cancer in 17 (%77) and 5 (%23) patients, respectively. Location of primary tumor is distal, proximal and mid-esophagus in 13 (%59), 6 (%27) and 3 (%13) patients, respectively. Primary tumor of all the patients were FDG avid (mean SUV_max: 18.85±7.0; range: 5.5-35.1). Additionally, ¹⁸F-FDG uptake was seen in mediastinal lymph nodes in 13 patients (5.45±8.15; range: 2.6-29.9). Mean metabolic tumor volumes of primary esophageal lesions were calculated as 8.77±8.46cm³ (range: 2.3-34.2). Mean MTV of lymph nodes was 2.44±1.01cm³ (range: 0.4-3.6). Mean total metabolic tumor volume was calculated as 9.99±8.58cm³ (range: 2.3-27.3). 10 patients died during 447±121 days follow-up period. Mean survival time was 11.9±1.5 months (95%CI: 8.99-14.74) for entire patient group. Total metabolic tumor volume had a significant effect on survival (p=0.045) according to Cox proportional hazards regression analysis. One unit increase in MTV caused 1.1 (95%CI:1.003-1.196) fold increase in hazard, at any time.

Conclusion: Definition of preoperative metabolic tumor volume has a prognostic value in the prediction of postoperative survival times. Patients who have higher preoperative metabolic tumor volumes could be good candidates for more aggressive chemo-radiation therapy regiments.

Conflict of interest:None declared.

Vitamin D to prevent acute lung injury following oesophagectomy (VINDALOO): study protocol for a randomised placebo controlled trial

Background

Acute lung injury occurs in approximately 25% to 30% of subjects undergoing oesophagectomy. Experimental studies suggest that treatment with vitamin D may prevent the development of acute lung injury by decreasing inflammatory cytokine release, enhancing lung epithelial repair and protecting alveolar capillary barrier function.

Methods/Design

The ‘Vitamin D to prevent lung injury following oesophagectomy trial’ is a multi-centre, randomised, double-blind, placebo-controlled trial. The aim of the trial is to determine in patients undergoing elective transthoracic oesophagectomy, if pre-treatment with a single oral dose of vitamin D₃ (300,000 IU (7.5 mg) cholecalciferol in oily solution administered seven days pre-operatively) compared to placebo affects biomarkers of early acute lung injury and other clinical outcomes. The primary outcome will be change in extravascular lung water index measured by PiCCO® transpulmonary thermodilution catheter at the end of the oesophagectomy. The trial secondary outcomes are clinical markers indicative of lung injury: PaO₂:FiO₂ ratio, oxygenation index; development of acute lung injury to day 28; duration of ventilation and organ failure; survival; safety and tolerability of vitamin D supplementation; plasma indices of endothelial and alveolar epithelial function/injury, plasma inflammatory response and plasma vitamin D status. The study aims to recruit 80 patients from three UK centres.

Discussion

This study will ascertain whether vitamin D replacement alters biomarkers of lung damage following oesophagectomy.

Trial registration

Current Controlled Trials ISRCTN27673620

Prevention of postoperative pulmonary complications through intensive preoperative respiratory rehabilitation in patients with esophageal cancer

Postoperative pulmonary complications (PPCs) after esophagectomy have been reported to occur in 15.9-30% of patients and lead to increased postoperative morbidity and mortality, prolonged duration of hospital stay, and additional medical costs. The purpose of this retrospective cohort study was to investigate the possible prevention of PPCs by intensive preoperative respiratory rehabilitation in esophageal cancer patients who underwent esophagectomy. The subjects included 100 patients (87 males and 13 females with mean age 66.5 ± 8.6 years) who underwent esophagectomy. They were divided into two groups: 63 patients (53 males and 10 females with mean age 67.4 ± 9.0 years) in the preoperative rehabilitation (PR) group and 37 patients (34 males and 3 females with mean age 65.0 ± 7.8 years) in the non-PR (NPR) group. The PR group received sufficient preoperative respiratory rehabilitation for >7 days, and the NPR group insufficiently received preoperative respiratory rehabilitation or none at all. The results of the logistic regression analysis and multivariate analysis to correct for all considerable confounding factors revealed the rates of PPCs of 6.4% and 24.3% in the PR group and NPR group, respectively. The PR group demonstrated a significantly less incidence rate of PPCs than the NPR group (odds ratio: 0.14, 95% confidential interval: 0.02~0.64). [Correction added after online publication 25 June 2012: confidence interval has been changed from -1.86~ -0.22] This study showed that the intensive preoperative respiratory rehabilitation reduced PPCs in esophageal cancer patients who underwent esophagectomy.

Does obesity affect outcomes in patients undergoing esophagectomy for cancer? A meta-analysis

BACKGROUND

The incidence of esophageal carcinoma and the global prevalence of obesity are both increasing. As a result, there is an increased number of esophagectomies being performed on obese patients. The identification of specific complications in obese patients undergoing esophagectomy may allow improved risk assessment and postoperative management to reduce morbidity and mortality. This meta-analysis aimed to determine whether obese patients are at increased risk of postoperative complications, mortality, and compromised survival compared to non-obese patients following esophageal resection.

METHODS

A Medline, Embase, Ovid, and Cochrane database search was performed on all articles between January 1980 and January 2012 comparing post-esophagectomy outcomes between obese and non-obese patients. This study was conducted in accordance with the recommendations of the Cochrane Collaboration and the Quality of Reporting of Meta-Analyses guidelines.

RESULTS

There was no significant difference between obese and non-obese patients with respect to extent of tumor resection, cardiorespiratory complications, anastomotic leakage, reoperation rates, wound infection, or postoperative mortality. Meta-regression analysis showed that diabetes in obese patients was associated with a significant impact on the risk of anastomotic leakage (coefficient = -7.94 [-15.24-0.65, P = 0.03) and atrial fibrillation (coefficient = -6.94 [-12.79-1.10], P = 0.02). Overall, obese patients had significantly better long-term survival than non-obese patients (Hazard Ratio = 0.78 [0.64-0.96], P = 0.02).

CONCLUSIONS

In patients who are eligible for surgery, obesity alone does not increase risk of postoperative complications or mortality and should not be an independent contraindication for esophagectomy. However, the presence of diabetes mellitus in conjunction with obesity may be associated with increased risk of anastomotic leakage and atrial fibrillation. Because of the adverse physiological remodeling in obesity, surgeons should maintain a low threshold for the investigation and management of complications and ensure meticulous management of co-morbidities. Obesity may also improve long-term postoperative survival after esophageal surgery, although further studies with higher levels of evidence are necessary to fully determine any advantageous effects of obesity following oncological esophageal surgery.

Medical evaluation of patients preparing for an esophagectomy

Despite important improvements in the multimodal treatment of upper gastrointestinal tumors in recent years, surgery is still the standard of care and the best way to cure and palliate patients with esophageal cancer. There has been significant improvement in both clinical oncologic staging and functional preoperative evaluation of patients in the last few decades. Despite improvements, esophagectomy is still associated with high operative risk. Diligent perioperative evaluation and risk stratification lead to better outcomes.

Risk factors for postoperative respiratory complications following esophageal cancer resection

The development of surgical and postoperative management techniques has improved the treatment outcomes of esophageal cancer resection. However, respiratory morbidity is still the most frequent complication after esophagectomy. The objective of the present study was to identify risk factors for respiratory complications following resection for esophageal cancer. This study included 96 patients with esophageal cancer who had undergone esophagectomy with lymph node dissection. The patients were divided into 2 groups according to the presence (20 patients, 17 had pneumonia and 3 had acute respiratory distress syndrome) or absence (76 patients) of postoperative respiratory complications (PRC). The two groups were compared with respect to their preoperative clinical variables, such as age, body mass index, smoking history, serum albumin, serum C-reactive protein (CRP), number of lymphocytes, %VC, FEV1.0% and FEV1.0. Furthermore, multiple logistic regression analyses were used to estimate relative risk factors for respiratory complications. Results of the univariate analysis showed that smoking history (+/-, patients with PRC, 19/1 and without PRC, 53/23), serum CRP (≥1.0 mg/dl/<1.0 mg/dl, patients with PRC, 6/14 and without PRC, 6/70) and FEV1.0% (≥60%/<60%, patients with PRC, 16/4 and without PRC, 73/3) were significantly different between the two groups. Multiple logistic regression analysis showed that FEV1.0% was the strongest predictor of PRC. FEV1.0%, serum CRP and smoking history are reliable predictors of the risk of respiratory complications following esophageal cancer resection. For patients with these factors, perioperative management for the prevention of postoperative respiratory complications should be considered.

Pulmonary Complications due to Esophagectomy

INTRODUCTION

Esophageal carcinoma is the scourge of human beings. Pulmonary complications in patients who have undergone operation are common (20-30% of cases) and there are no suitable tools and ways to predict these complications.

METHODS

During a period of 10 years, from March 1998 to February 2007, 200 patients (150 male and 50 female) underwent Esophagectomy due to esophageal carcinoma in thoracic surgery ward retrospectively. Complications include the length of hospitalization, mechanical ventilation, morbidity and mortality. Patients' risk factors include age, preoperative chemo-radiotherapy, stage of the disease and preoperative spirometry condition.

RESULTS

WE GROUPED OUR PATIENTS INTO THREE CATEGORIES: Normal (FEV1 ≥ 80% predicted), mildly impaired (FEV1 65% to 79% predicted), more severely impaired (FEV1 < 65% predicted).Although almost all patients had radiographic pulmonary abnormalities, significant pulmonary complications occurred in 40 patients (20%) which underwent Esophagectomy. Pleural effusion and atelectasia in 160 patients (80%). 24 patients needed chest-tube insertion. 20 patients (10%) developed ARDS. 14 patients (7%) developed chylothorax. 20 patients (10%) of patients died during their postoperative hospital stay. 30 patients (15%) required mechanical ventilation for greater than 48 hours.

CONCLUSION

We reviewed a number of preoperative clinical variables to determine whether they contributed to postoperative pulmonary complications as well as other outcomes. In general, age, impaired pulmonary function especially in those patients with FEV1 less than 65% predicted was associated with prolonged hospital length of stay (LOS). In fact pulmonary complications rate after Esophagectomy are high and there was associated mortality and morbidity.

Influence of visceral obesity for postoperative pulmonary complications after pancreaticoduodenectomy

BACKGROUND

We conduct this study to determine whether postoperative complications, including postoperative pulmonary complications (PPCs), are associated with BMI and visceral fat area (VFA) after pancreaticoduodenectomy.

METHODS

A total of 317 patients undergoing pancreaticoduodenectomy were enrolled. VFA was measured using a cross-sectional computed tomography (CT) scan at the level of the umbilicus by FatScan software version 3.0 (N2 systems Inc., Osaka, Japan). Clinicopathological variables, intraoperative outcomes, and postoperative courses were analyzed.

RESULTS

Of all patients, 130 (41.0%) had postoperative complications and PPCs occurred in 14 patients (4.4%). VFA were significantly higher in patients who developed postoperative pancreatic fistula (POPF), PPCs, and mortality than in those patients who did not (P = .0282, P = .0058, and P = .0173, respectively). Multivariate analysis demonstrated that high BMI and high VFA were not independent predictive risk factors for POPF grade B/C and mortality; only high VFA was an independent risk factor influencing PPCs (P = .0390, odds ratio 4.246, 95% confidence interval 1.076-16.759).

CONCLUSIONS

Visceral obesity was the independent risk factor for the incidence of PPCs after pancreaticoduodenectomy. Preoperative VFA measurement using CT scan is a useful tool for the prediction of the development of PPCs compared to BMI calculation.

Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database

INTRODUCTION

This report describes the case mix and outcomes of patients with oesophageal cancer admitted to adult critical care units following elective oesophageal surgery in England, Wales and Northern Ireland.

METHODS

Admissions to critical care following elective oesophageal surgery for malignancy were identified using data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. Information on admissions between December 1995 and September 2007 were extracted and the association between in-hospital mortality and patient characteristics on admission to critical care was assessed using multiple logistic regression analysis. The performance of three prognostic models (Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and the ICNARC physiology score) was also evaluated.

RESULTS

Between 1995 and 2007, there were 7227 admissions to 181 critical care units following oesophageal surgery for malignancy. Overall mortality in critical care was 4.4% and in-hospital mortality was 11%, although both declined steadily over time. Eight hundred and seventy-three (12.2%) patients were readmitted to critical care, most commonly for respiratory complications (49%) and surgical complications (25%). Readmitted patients had a critical care unit mortality of 24.7% and in-hospital mortality of 33.9%. Overall in-hospital mortality was associated with patient age, and various physiological measurements on admission to critical care (partial pressure of arterial oxygen (PaO2):fraction of inspired oxygen (FiO2) ratio, lowest arterial pH, mechanical ventilation, serum albumin, urea and creatinine). The three prognostic models evaluated performed poorly in measures of discrimination, calibration and goodness of fit.

CONCLUSIONS

Surgery for oesophageal malignancy continues to be associated with significant morbidity and mortality. Age and organ dysfunction in the early postoperative period are associated with an increased risk of death. Postoperative serum albumin is confirmed as an additional prognostic factor. More work is required to determine how this knowledge may improve clinical management.

18F-FAMT-PET is useful for the diagnosis of lymph node metastasis in operable esophageal squamous cell carcinoma

BACKGROUND

The role and potential usefulness of positron emission tomography (PET) scanning in certain tumors has been widely investigated in recent years. (18)F-FAMT (L-[3-(18)F]-α-methyltyrosine) is an amino acid tracer for PET. This study investigated whether PET/CT with (18)F-FAMT provides additional information for preoperative diagnostic workup of esophageal squamous cell carcinoma compared with that obtained by (18)F-FDG (fluorodeoxyglucose) PET or CT.

METHODS

PET/CT studies with (18)F-FAMT and (18)F-FDG were performed as a part of the preoperative workup in 21 patients with histologically confirmed esophageal squamous cell carcinoma.

RESULTS

For the detection of primary esophageal cancer, (18)F-FAMT-PET exhibited a sensitivity of 76.2%, whereas the sensitivity for (18)F-FDG-PET was 90.5% (P = 0.214). (18)F-FAMT uptake in primary tumors showed significant correlation with depth of invasion (P = 0.005), lymph node metastasis (P = 0.045), stage (P = 0.031), and lymphatic invasion (P = 0.029). In the evaluation of individual lymph node groups, (18)F-FAMT-PET exhibited 18.2% sensitivity, 100% specificity, 71.9% accuracy, 100% positive predictive value, and 70.0% negative predictive value, compared with 24.2%, 93.7%, 69.8%, 66.6%, and 70.2%, respectively, for (18)F FDG-PET. CT exhibited 39.4% sensitivity, 85.7% specificity, 69.8% accuracy, 59.1% positive predictive value, and 73.0% negative predictive value. The specificity of (18)F-FAMT-PET is significantly higher than that of (18)F-FDG-PET (P = 0.042) and CT (P = 0.002). (18)F-FAMT-PET did not have any false-positive findings compared to those with (18)F-FDG-PET.

CONCLUSIONS

Our findings suggest that the addition of (18)F-FAMT-PET to (18)F-FDG-PET and CT would permit more precise staging of esophageal cancer.

Preoperative risk assessment and prevention of complications in patients with esophageal cancer

In this review the preoperative risk assessment and prevention of complications in patients undergoing esophagectomy for cancer is discussed. Age, pulmonary and cardiovascular condition, nutritional status, and neoadjuvant chemo(radio)therapy are known predictive factors. None of these factors is a valid exclusion criterion for esophagectomy, but may help in careful patient selection. Both anesthetists and surgeons play an important role in intraoperative risk reduction by means of appropriate fluid management and application of optimal surgical techniques.

Determination of the irradiation field for clinical T1-T3N0M0 thoracic/abdominal esophageal cancer based on the postoperative pathological results

OBJECTIVE

In patients with thoracic/abdominal esophageal cancer with no clinical evidence of lymph node metastasis, there is no consensus about whether the irradiation field should include regional lymph nodes. In this study, the extent of the irradiation field for clinical stage T1-3N0M0 esophageal cancer was determined based on the postoperative pathological results.

METHODS

From July 1989 to June 2008, 103 patients diagnosed with clinical stage T1-3N0M0 thoracic/abdominal esophageal cancer underwent standard esophagectomy and regional lymph node dissection at the Aichi Cancer Center Hospital. Of these 103 patients, the pathological results of the resected specimens could be confirmed in 95 (92%) patients. The pathological lymphatic spread was reviewed retrospectively, and the extent of the irradiation field was determined based on the postoperative pathological results.

RESULTS

Of 95 patients with clinical stage T1-3N0M0 esophageal cancer, 40 (42.1%) had pathological lymph node metastases, and the frequency of nodal metastases was studied by tumor location. The rates of lymph node metastases for the upper, middle, lower and abdominal esophagus were 37.5%, 32.5%, 46% and 70%, respectively.

CONCLUSIONS

Pathological lymph nodes metastases are often seen after operation in clinical stage T1-3N0M0 esophageal cancer. In the present study, the optimal lymph nodes to be included in the irradiation field were determined according to the primary site in the esophagus.

Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery

BACKGROUND

Surgical outcomes after thoracoscopic esophagectomy were compared with those after open esophagectomy, and the prognostic values of factors potentially related to mortality and morbidity were evaluated.

METHODS

We performed a retrospective chart review of 153 patients who underwent esophagectomy for thoracic esophageal cancer. The thoracic surgical procedures were categorized into the following three groups: esophagectomy under standard thoracotomy (n = 37), assisted thoracoscopic esophagectomy with utility minithoracotomy (n = 38), and complete thoracoscopic esophagectomy (n = 78). Mortality and morbidity were compared among the three groups. Then, in a separate multivariate analysis, data on 14 potentially prognostic variables were extracted, and the relation to postoperative outcomes was examined.

RESULTS

Respiratory complications were the most frequent complications in all three groups, and their rate of occurrence was not significantly among the three groups. The 30-day and in-hospital mortality rates were significantly higher in the open group than in the other groups. Multivariate analysis demonstrated that patient age, sex, induction chemoradiation, and forced expiratory volume were independently significant contributing factors for respiratory complications, while the serum total protein concentration and open esophagectomy were significant factors for in-hospital mortality.

CONCLUSIONS

Our results demonstrated that respiratory complications are still the main cause of operative morbidity when using the thoracoscopic esophagectomy protocol and that use of the thoracoscopic procedure does not decrease the risk of respiratory complications. The use of the thoracoscopic procedure improved postoperative in-hospital mortality. The advantages of thoracoscopic esophagectomy should be investigated further. At this point in time, however, thoracoscopic esophagectomy can be considered a feasible, safe, and advantageous surgical option.

Cancer of the esophagus: the value of preoperative patient assessment

In the past few years, major improvements and new technologies have been proposed and applied in esophageal surgery. Its evolution depended not only on a thorough knowledge of surgical anatomy and technique, but also on important developments in pre- and postoperative care. Esophageal resection for cancer is still associated with high morbidity and mortality. Postoperative complications may be either patient or surgeon related. Patient-related factors include age, malnutrition, immunodepression and associated diseases. The surgeon-related factors are surgical experience, hospital volume and multidisciplinary approach. Preoperative evaluation is defined as the process of clinical assessment that precedes the delivery of anesthesia. The principle is to gain information concerning patients that leads to modification of their management, and improves the outcome from surgery.

Randomized clinical trial to determine the effect of nasogastric drainage on tracheal acid aspiration following oesophagectomy

BACKGROUND

The aim of this study was to investigate tracheal acid aspiration after oesophagectomy and to determine whether it is influenced by nasogastric (NG) drainage.

METHODS

Thirty-four patients undergoing oesophagectomy were randomized to one of three methods of NG drainage: a single-lumen tube with free drainage and 4-hourly aspiration, a sump-type tube on continuous suction drainage, or no NG tube. A tracheal pH probe was used to collect information on acid aspiration for 48 h after surgery. A pH < 5.5 was considered abnormal (normal pH 6.8-7.2). Total time with tracheal pH < 5.5, number of reflux episodes and longest reflux time were compared between groups.

RESULTS

There was significant and persistent tracheal acid aspiration in all patients. Patients with a sump-type tube had a significantly shorter total time with tracheal pH < 5.5 than those in the other groups (sump-type tube versus single-lumen tube, P = 0.0069; sump-type tube versus no tube, P = 0.0071). Patients randomized to no NG tube experienced more respiratory complications after surgery than those who had either single-lumen or sump-type tubes (seven of 12 versus four of 22 patients; P = 0.023). Insertion of a NG tube was necessary in the first week after surgery in seven of 12 patients in this group.

CONCLUSION

Routine NG drainage after oesophagectomy is necessary. A sump-type NG tube is better at preventing tracheal acid aspiration and may reduce the incidence of respiratory complications.

Pulmonary complications in patients with chronic obstructive pulmonary disease following transthoracic esophagectomy

AIM: To investigate the incidence of various types of postoperative pulmonary complications (POPCs) and to evaluate the significance of perioperative arterial blood gases in patients with esophageal cancer accompanied with chronic obstructive pulmonary disease (COPD) after esophagectomy.

MEHTODS: Three hundred and fifty-eight patients were divided into POPC group and COPD group. We performed a retrospective review of the 358 consecutive patients after esophagectomy for esophageal cancer with or without COPD to assess the possible influence of COPD on postoperative pulmonary complications. We classified COPD into four grades according to percent-predicted forced expiratory volume in 1 s (FEV1) and analyzed the incidence rate of complications among the four grades. Perioperative arterial blood gases were tested in patients with or without pulmonary complications in COPD group and compared with POPC group.

RESULTS: Patients with COPD (29/86, 33.7%) had more pulmonary complications than those without COPD (36/272, 13.2%) (P < 0.001). Pneumonia (15/29, 51.7%), atelectasis (13/29, 44.8%), prolonged O₂ supplement (10/29, 34.5%), and prolonged mechanical ventilation (8/29, 27.6%) were the major complications in COPD group. Moreover, patients with severe COPD (gradeIIB, FEV1 < 50% of predicted) had more POPCs than those with moderate(gradeIIA, 50%-80% of predicted) and mild (gradeI≥ 80% of predicted) COPD (P < 0.05). PaO₂ was decreased and PaCO₂ was increased in patients with pulmonary complications in COPD group in the first postoperative week.

CONCLUSION: The criteria of COPD are the critical predictor for pulmonary complications in esophageal cancer patients undergoing esophagectomy. Severity of COPD affects the incidence rate of the pulmonary complication, and percent-predicted FEV1 is a good predictive variable for pulmonary complication in patients with COPD. Arterial blood gases are helpful in directing perioperative management.

Effect of perioperative steroid therapy on the postoperative course of patients with oesophageal cancer

BACKGROUND

Perioperative steroid therapy is often used in oesophageal cancer surgery and we evaluate the effect of this therapy on the secretory leukocyte protease inhibitor levels in the lungs (a major antiprotease in the conducting airways) and postoperative course in oesophageal cancer patients.

METHODS

Twenty-one patients operated on for oesophageal cancer in 2003-2004 were treated with perioperative steroid therapy (250 mg of methylprednisolone intravenously 1 h before the operation). Fifteen consecutive patients operated on in 2002 served as a control group. Secretory leukocyte protease inhibitor in bronchoalveolar lavage fluid and the postoperative course in the two groups were compared.

RESULTS

The mortality rate was 0% and there was no significant difference in the morbidity rate between the two groups. Days of intubation and systemic inflammatory response syndrome were significantly shorter for the steroid group. The bronchoalveolar lavage fluid secretory leukocyte protease inhibitor level was significantly higher in the steroid group than in the control group on postoperative days 2 and 3. The secretory leukocyte protease inhibitor level on postoperative day 3 was remarkably lower for the patients intubated for > or = 5 days and for those with pulmonary complications.

CONCLUSION

Perioperative steroid therapy increased the bronchoalveolar lavage fluid secretory leukocyte protease inhibitor level and reduced the days of intubation and systemic inflammatory response syndrome in patients with oesophagectomy.

Relationship between secretory leukocyte protease inhibitor levels in bronchoalveolar lavage fluid and postoperative pulmonary complications in patients with esophageal cancer

BACKGROUND

We investigated whether secretory leukocyte protease inhibitor (SLPI) is associated with pulmonary complications after esophagectomy.

METHODS

We measured serial changes in the SLPI concentration in the bronchoalveolar lavage fluid (BALF) of 34 patients who underwent and examined the relationship between SLPI and postoperative morbidity.

RESULTS

Fifteen (44%) of 34 patients (high group) had a BALF SLPI concentration >90,000 pg/mL at the end of the surgery (postoperative day [POD] 0). There was no significant difference between the high group and other 19 patients (low group) with respect to age, sex, preoperative comorbid conditions, tumor stage, surgical technique, operating time, or blood loss volume. Days of intubation and pulmonary complication rate were significantly increased in the high group compared with the low group. Logistic regression analysis revealed that the BALF SLPI level on POD 0 was significant for pulmonary complications.

CONCLUSIONS

Our results indicate that assaying SLPI levels in BALF can be useful for the prediction of pulmonary complications after esophagectomy.

Association of angiotensin-converting enzyme insertion/deletion polymorphism with serum level and development of pulmonary complications following esophagectomy

BACKGROUND

Pulmonary complications remain the major cause of postoperative mortality in patients with esophageal cancer undergoing esophagectomy. It was unclear whether this dismal complication has a genetic predisposition. We therefore investigated the role of an angiotensin-converting enzyme (ACE) insertion/deletion polymorphism in developing these complications.

METHODS

We conducted a prospective study including 152 patients with esophageal cancer who underwent esophagectomy in National Taiwan University Hospital between 1996 and 2002. The ACE genotype was determined by polymerase chain reaction amplification of leukocyte DNA obtained before surgery. The serum ACE concentration was determined by enzyme-linked immunosorbent assay.

RESULTS

Thirty-five patients (23%) developed pulmonary complications following esophagectomy. As compared with patients with the I/I and I/D genotypes, those with the D/D genotype had a higher risk for pulmonary complications (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.01-9.65). The risk was additively enhanced by combination of the ACE D/D genotype with other clinical risk factors (old age, hypoalbuminemia, and poor pulmonary function). The circulating ACE level was also dose-dependently with the presence of ACE D allele. As compared with the patients with circulating ACE less than 200 ng/mL, the patients with circulating ACE of 200 to 400 ng/mL and over 400 ng/mL had ORs (95% CI) of 2.75 (1.12-6.67) and 15.00 (4.3-52.34) to present with ACE D allele, respectively.

CONCLUSIONS

An ACE insertion/deletion polymorphism might modulate the function of ACE gene and play a role in affecting individual susceptibility to pulmonary injury following esophagectomy in patients of esophageal cancer.

Interferon-gamma and granulocyte colony-stimulating factor in bronchoalveolar lavage fluid after oesophagectomy

BACKGROUND

Activated polymorphonuclear leucocytes play a pivotal role in pulmonary complications after oesophagectomy. A lot of inflammatory mediators including interferon-gamma and granulocyte colony-stimulating factor are reported to modify the life span of polymorphonuclear leucocytes.

AIMS

In this study we investigated whether interferon-gamma and granulocyte colony-stimulating factor are associated with pulmonary complications after oesophagectomy.

PATIENTS AND METHODS

We measured interferon-gamma and granulocyte colony-stimulating factor concentrations in bronchoalveolar lavage fluid of 37 patients who had undergone oesophagectomy and examined the relationship between these mediators and pulmonary complications.

RESULTS

Pulmonary complications occurred in nine patients (24%, Pneum(+)). There was no significant difference in age, gender, preoperative comorbid conditions, tumour stage, operation method, operating time or blood loss between the Pneum(+) group and another 28 patients(Pneum(-)). Days until extubation were significantly increased in the Pneum(+) group than in the Pneum(-) group. Interferon-gamma (on postoperative day 2) and granulocyte colony-stimulating factor (on postoperative days 1-3) in bronchoalveolar lavage fluid were significantly increased in the Pneum(+) group than in the Pneum(-) group and granulocyte colony-stimulating factor was significantly correlated with days until extubation.

CONCLUSIONS

Our results indicate that bronchoalveolar lavage fluid granulocyte colony-stimulating factor is associated with respiratory conditions after oesophagectomy and assaying it can be useful for predicting pulmonary complications.

Body Fat Accumulation and Postoperative Complications after Abdominal Surgery

The contribution of subcutaneous or intra-abdominal fat (SCF, IAF) accumulation to postoperative mortality or morbidity after elective gastric or colorectal cancer surgery was studied. One hundred thirty-nine patients who underwent gastric or colorectal cancer surgery were investigated. Data were collected on the following preoperative comorbid conditions: lung dysfunction, cardiovascular dysfunction, liver dysfunction, or diabetes mellitus (DM). The IAF and SCF areas were determined at the umbilical level by preoperative CT scanning. We investigated whether IAF or SCF was independently associated with postoperative mortality or morbidity. The mortality rate was 0.7 per cent (1/139). Nineteen (14%) of 139 patients had medical complications (pneumonitis or arrhythmia) and 27 (19%) had surgery-related complications (anastomotic leakage, intra-abdominal collections, or abdominal wound infection) postoperatively. Age (≥70 years), lung dysfunction, cardiovascular dysfunction, and IAF were significantly associated with medical complications, and surgical site (gastric/colorectal), DM, body mass index, IAF, and SCF were significant for surgery-related complications by univariate analysis. Multilogistic regression analysis showed that age, cardiovascular dysfunction, and IAF were significant for medical complications, and surgical site, DM, and SCF were independently related with surgery-related complications. Body fat accumulation is independently associated with postoperative morbidity after gastric or colorectal surgery, and assaying it may be useful for predicting postoperative complications.

Immunonutrition risk factors of respiratory complications after esophagectomy

BACKGROUND

There are many reports suggesting predictive factors for respiratory complications after esophagectomy, but few studies have focused on this problem from the aspect of immunonutrition.

METHODS

A series of 45 esophageal cancer patients who underwent potentially curative resection between April 1996 and March 2001 was enrolled in this study. Preoperative and intraoperative variables were analyzed for a correlation between risk factors and respiratory complications. In this study, immunonutrition variables as assessed by ultrasonography and indirect calorimetry were used. Uni- and multivariate analyses were performed to determine the predictive factors.

RESULTS

Of 45 patients, nine patients (20%) developed respiratory complications. In univariate analysis, forced expiratory volume in 1 s per body surface area (m(2)) in preoperative respiratory parameters, respiratory quotient, and caloric contributions of fat (percentage) and carbohydrate according to indirect calorimetry, and serum CH50 level significantly influenced the occurrence of postoperative respiratory complications. In multivariate analysis, the caloric contribution of fat (percentage) by indirect calorimetry and serum alpha(1)-antitrypsin (serine protease inhibitor) independently affected the occurrence of respiratory complications.

CONCLUSIONS

Preoperative excessive fat oxidation (potential starvation) and alpha(1)-antitrypsin were independent predictive factors for postoperative complications. Nutrition support such as enteral feeding to improve this malnourished state would reduce the incidence of postoperative respiratory complications.

[Surgery for oesophageal cancer: current controversies]

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.

Correlation between serum melatonin circadian rhythm and intensive care unit psychosis after thoracic esophagectomy

BACKGROUND

Intensive care unit (ICU) psychosis is still a relatively frequent complication after esophageal surgery. We investigated the correlation between ICU psychosis and serum melatonin concentration during the period after esophagectomy.

METHODS

The study group comprised 41 patients who underwent esophagectomy for treatment of esophageal cancer between 1999 and 2001. The cohort included 36 men and 5 women, aged 36 to 78 years. After surgery, blood samples were collected 4 times a day for 4 days. Serum levels of melatonin were determined with a melatonin radioimmunoassay kit. The regularity of the melatonin circadian rhythm pattern, as defined by the frequency of occurrence of the peak level of melatonin secretion, was determined (the pattern was described as irregular at less than 3 times in the measurement period).

RESULTS

Of the 41 patients who met the inclusion criteria, 11 (26.8%) had ICU psychosis develop. These patients were older than those patients in whom ICU psychosis did not develop (P =.01). No significant differences were seen in the duration of surgery, volume of blood loss, term in the ICU, term of intubation, tumor location, disturbances of organ function, and postoperative complications between patients in whom ICU psychosis developed, and those patients in whom it did not. Patients with ICU psychosis tended to have abnormally low serum levels of melatonin. Of the 41 patients studied, 9 (22%) had an irregular pattern of melatonin circadian rhythm. A significant correlation was seen between ICU psychosis and an irregular melatonin circadian rhythm (P =.0001).

CONCLUSION

Irregular patterns of melatonin circadian rhythm may be associated with ICU psychosis. Supplementation with melatonin, or acceleration of melatonin secretion, may protect patients from development of ICU psychosis and may promote recovery to a normal mental state.

Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy

Anastomotic insufficiency is considered to be one of the most serious complications associated with esophageal reconstruction. The purposes of this study were to identify (1) the relationship between anastomotic insufficiency and tissue blood flow (TBF) in the gastric tube in the perioperative period, and (2) the effects of intravenous prostaglandin E1 (PGE1) on TBF in the gastric tube. The study group consisted of 44 patients who were to undergo esophagectomy for esophageal cancer. Intraoperative and postoperative TBF on the serosal side of the gastric tube were measured by laser-Doppler tissue blood flowmetry. The TBF of the Leakage(+) group (n = 5) was poorer than that of the Leakage(?) group (n = 39) during the intraoperative and postoperative periods. There was a significant difference in TBF between the two groups at postoperative day (POD) 3. There was a tendency in the PGE1(+) group (n = 18) to exhibit richer blood flow through the anastomosis than the PGE1(?) group (n = 26), intraoperatively, but the difference was not significant. Two of five Leakage(+) cases were also in the PGE1(+) group. There was no relationship between intraoperative medication with PGE1 and incidence of leakage. The TBF of three-field lymph node dissection and reconstruction of the retrosternal route group (n = 21) was poorer than that of the two-field lymph-node dissection and reconstruction of the posterior mediastinal route group (n = 23). The TBF in the gastric tube after esophagectomy may be a predictor of anastomotic insufficiency. However, PGE1 treatment in the intraoperative period alone is not effective in preventing anastomotic insufficiency.

Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma

AIMS

The relationship between the pre-operative nutritional condition and the outcome of the surgical treatment in patients with oesophageal carcinoma has been discussed diversely. The aim of the current study was to demonstrate the relationship between pre-operative nutritional condition and post-operative complications and prognosis following surgical treatment for oesophageal carcinoma.

METHODS

Two hundred and fifty-eight patients with oesophageal carcinoma treated with oesophageal resection and reconstruction were selected. The correlation of pre-operative values of prognostic nutritional index (PNI) with the incidence of post-operative complications and prognosis of the patients was investigated.

RESULTS

The mean pre-operative value of PNI in patients with post-operative complications (41.8+/-5.4) was significantly lower than that in patients without post-operative complications (46.5+/-5.3; P<0.0001). The survival in patients with higher PNI value was significantly more favourable than that in patients with lower PNI value (P=0.0001).

CONCLUSIONS

Pre-operative assessment of the nutritional condition could provide predictive information for post-operative complications in patients with oesophageal carcinoma.

Comparison between positron emission tomography and computed tomography in the use of the assessment of esophageal carcinoma

BACKGROUND

The role and potential value of positron emission tomography (PET) scanning in certain tumors has been widely investigated in recent years. The authors retrospectively assessed the performance of 18-F-fluorodeoxyglucose (FDG)-PET in the assessment of esophageal squamous cell carcinoma (SCC).

METHODS

The results using PET were compared with those using computed tomography (CT), and these were correlated with the pathologic findings. The authors studied 32 patients with thoracic esophageal SCC who had undergone radical esophagectomy.

RESULTS

Uptake of FDG in the primary tumor was found in 25 of the 32 (78.1%) cases. Comparison of the FDG uptake and the clinicopathologic findings showed that there was a significant association between the FDG uptake and each of the depth of tumor invasion (P < 0.05), occurrence of lymph node metastasis (P < 0.01), and lymphatic invasion (P < 0.01). The survival rate in cases with high FDG uptake (standardized uptake value [SUV], >3) was significantly lower than that in cases with low FDG uptake (SUV, < 3; P < 0.05). In the evaluation of lymph node staging by the detection of lymph node metastasis, FDG-PET showed 77.8% sensitivity, 92.9% specificity, and 84.4% accuracy, and CT scanning showed 61.1% sensitivity, 71.4% specificity, and 65.6% accuracy. Positron emission tomography scanning showed a high degree of accuracy in the neck, upper thoracic, and abdominal regions. However, in the mid- and lower thoracic regions, the sensitivity was very low. The smallest lymph node metastasis that was detected by FDG-PET imaging was 6 mm. The average size of lymph node metastasis that was undetected by FDG-PET scanning was 7.3 mm (range, 1-17 mm).

CONCLUSIONS

In conclusion, FDG-PET may be used as a noninvasive diagnostic technique in assessing the aggressiveness of the tumor and the prognosis in patients with esophageal SCC. During the preoperative diagnostic procedures, the sensitivity, specificity, and accuracy of lymph node staging is higher with FDG-PET than with CT imaging. In view of the high specificity of FDG-PET, it also gives useful information to guide the choice of treatment of esophageal carcinoma.

Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer

OBJECTIVES

Pulmonary complication is a frequent morbid event after esophagectomy for cancer. Its prediction may help select patients for preoperative rehabilitation.

METHODS

We performed a retrospective review of 292 patients (231 men and 61 women; mean age, 60.1 years) who underwent esophagectomy for cancer between 1980 and 2000. Data were analyzed to identify factors associated with the development of pulmonary complications (reintubation for isolated respiratory failure and pneumonia). A scoring system was developed, and its ability to predict complications was assessed.

RESULTS

Resection was performed for squamous cancer (n = 100), adenocarcinoma (n = 186), and other histologic types (n = 6) in patients with stages 0 or I (n = 53), II (n = 94), III (n = 114), and IV (n = 23) disease. Pulmonary complications, which developed in 78 (27%) patients, were associated with a 4.5-fold increase in operative mortality (7%-32%). Multivariable analysis identified independent predictors of pulmonary complications to be patient age (odds ratio [OR], 1.31; 95% confidence interval [CI], 0.99-1.74; P =.059), percentage forced expiratory volume in 1 second (OR, 1.21; 95% CI, 1.07-1.38; P =.003), and possibly performance status (OR, 1.48; 95% CI, 0.88-2.50; P =.14). A scoring system using these 3 covariates was developed, which predicted incremental risk of pulmonary complications (P =.013). The incremental risks of cardiovascular and overall cardiopulmonary complications were also predicted with this scoring system (P <.01 for each).

CONCLUSIONS

A scoring system using patient age, spirometry, and performance status helps predict the likelihood of pulmonary and cardiovascular complications after esophagectomy and can help select patients who may benefit from preoperative cardiopulmonary rehabilitation.

Pulmonary complications after esophagectomy

BACKGROUND

Pulmonary complications are common in patients who have undergone esophagectomy. There are no good predictive variables for these complications. In addition, the role that preoperative treatment with chemotherapy and radiation may play in postoperative complications remains unclear.

METHODS

We performed a retrospective review of all patients who underwent esophagectomy by a single surgeon at our institution over a 6-year period. Data were analyzed for a correlation between patient risk factors and pulmonary complications, including mortality, prolonged mechanical ventilation, and hospital length of stay.

RESULTS

Complete data were available on 61 patients. Nearly all patients had some pulmonary abnormality (eg, pleural effusion), although most of these were clinically insignificant. Pneumonia was the most common clinically important complication, and 19.7% of patients required prolonged ventilatory support. Significant risk factors identified included impaired pulmonary function, especially for patients with forced expiratory volume in 1 second (FEV1) less than 65% of predicted, preoperative chemoradiotherapy, and age.

CONCLUSIONS

Impaired lung function is a significant risk factor for pulmonary complications after esophagectomy. Patients with FEV1 less than 65% of predicted appear to be at greatest risk. There also seems to be an associated risk of preoperative chemoradiotherapy for pulmonary complications after esophagectomy.

Predictive value of interleukin-8 and granulocyte elastase in pulmonary complication after esophagectomy

BACKGROUND

We investigated whether or not interleukin-8 (IL-8) and granulocyte elastase (GE) can be associated with pulmonary complication after esophagectomy (the most common cause of postoperative death).

METHODS

We measured serial changes in the IL-8 concentration and GE activity in the plasma and bronchoalveolar lavage fluid (BALF) of 17 patients who had undergone esophagectomy, and examined the relationship between these mediators and postoperative pulmonary complication.

RESULTS

Pulmonary complication occurred in 6 patients (35%, Pneum+ group). Plasma IL-8 increased at the end of the surgery then decreased, but there was no significant difference between the Pneum+ group and the group without pulmonary complication (11[65%], Pneum- group). IL-8 and GE in BALF were significantly higher in the Pneum+ group than in the Pneum- group on days 1 and 3 after the operation. There was a significant and positive correlation between IL-8 and GE in BALF.

CONCLUSIONS

Our results indicate that IL-8 and GE in BALF may be useful for the prediction of postoperative pulmonary complication.

Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients

OBJECTIVE

To evaluate the effects of maximizing the oxygen delivery on morbidity and mortality in patients >60 yrs of age and/or with chronic diseases of vital organs who underwent major elective surgery.

DESIGN

Prospective, randomized, controlled trial.

SETTING

A 24-bed general intensive care unit of a teaching hospital.

PATIENTS

Thirty-seven high-risk patients who underwent major surgery.

INTERVENTIONS

The hemodynamic and oxygen transport variables and outcomes in 18 patients (control group) treated to maintain normal values of oxygen delivery were compared with 19 patients (protocol group) treated to maintain "supranormal" values. Therapy in both groups consisted of volume expansion and, when necessary, dobutamine to reach target values, during the surgery and 24 hrs postoperatively.

MEASUREMENTS AND MAIN RESULTS

We interrupted the study because of a significant difference in the 60-day mortality rate. The mortality rate in the control group was significantly higher when compared with the protocol group (9/18 [50%] vs. 3/19 [15.7%], p < .05). The prevalence of clinical and infectious complications was higher in the control group than in the protocol group (67% and 31% respectively; relative risk, 0.47; 95% confidence interval, 0.226-0.991; p < .05) and there was a trend toward more severe organ dysfunction in nonachievers patients (17/24 [71%] vs. 6/13 [46%], relative risk, 0.65; 95% confidence interval, 0.343-1.237; NS).

CONCLUSION

Older patients with existing cardiorespiratory illness undergoing major surgery have a reduced morbidity and mortality when dobutamine is used to maximize oxygen transport.

Pulmonary function after cardiac and thoracic surgery

Cardiac and thoracic surgery cause alterations in ventilatory function that can lead to significant postoperative pulmonary complications. These complications often occur among patients with pre-existing pulmonary dysfunction and cause significantly longer hospital stays. This review explores some of the recent literature concerning this issue, including the effects of lung reduction surgery.