External validation of the Ferguson pulmonary risk score for predicting major pulmonary complications after oesophagectomy†

Prediction of Morbidity and Mortality After Esophagectomy: A Systematic Review

BACKGROUND

Esophagectomy for esophageal cancer has a complication rate of up to 60%. Prediction models could be helpful to preoperatively estimate which patients are at increased risk of morbidity and mortality. The objective of this study was to determine the best prediction models for morbidity and mortality after esophagectomy and to identify commonalities among the models.

PATIENTS AND METHODS

A systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and was prospectively registered in PROSPERO ( https://www.crd.york.ac.uk/prospero/ , study ID CRD42022350846). Pubmed, Embase, and Clarivate Analytics/Web of Science Core Collection were searched for studies published between 2010 and August 2022. The Prediction model Risk of Bias Assessment Tool was used to assess the risk of bias. Extracted data were tabulated and a narrative synthesis was performed.

RESULTS

Of the 15,011 articles identified, 22 studies were included using data from tens of thousands of patients. This systematic review included 33 different models, of which 18 models were newly developed. Many studies showed a high risk of bias. The prognostic accuracy of models differed between 0.51 and 0.85. For most models, variables are readily available. Two models for mortality and one model for pulmonary complications have the potential to be developed further.

CONCLUSIONS

The availability of rigorous prediction models is limited. Several models are promising but need to be further developed. Some models provide information about risk factors for the development of complications. Performance status is a potential modifiable risk factor. None are ready for clinical implementation.

Simultaneous transmediastinal esophagectomy and thoracoscopic lobectomy for synchronous double cancers of the esophagus and lung: a case report

BACKGROUND

Simultaneous surgery for synchronous double cancers of the esophagus and lung is so invasive that minimally invasive surgical procedures are preferred. For left lung cancer, there are few reports on simultaneous surgery due to the difficulty of performing radical esophagectomy only via the left thoracic approach and the high invasiveness of bilateral thoracotomy.

CASE PRESENTATION

A 65-year-old man who was diagnosed with synchronous double cancer of the esophagus and left lung underwent transmediastinal esophagectomy (TME) and thoracoscopic lobectomy (TSL) simultaneously. This procedure is advantageous because radical esophagectomy can be completed regardless of the side affected by the lung cancer, and respiratory function can be preserved by shortening the duration of differential lung ventilation and avoiding thoracotomy.

CONCLUSION

This surgery could be a good treatment option for synchronous double cancers of the esophagus and lung in a highly proficient hospital.

Pre- and intra-operative risk factors predict postoperative respiratory failure after minimally invasive oesophagectomy

OBJECTIVES

Severe pulmonary complications such as postoperative respiratory failure can occur after minimally invasive oesophagectomy. However, the risk factors have not been well identified. The goal of this study was to develop a predictive model for the occurrence of postoperative respiratory failure with a large sample.

METHODS

We collected data from patients with oesophageal cancer who had a minimally invasive oesophagectomy at Shanghai Chest Hospital from 2019 to 2022. Univariable and backward stepwise logistic regression analysis of 19 pre- and intra-operative factors was used before model fitting, and its performance was evaluated with the receiver operating characteristic curve. Internal validation was assessed with a calibration plot, decision curve analysis and area under the curve with 95% confidence intervals, obtained from 1000 resamples set by the bootstrap method.

RESULTS

This study enrolled 2,386 patients, 57 (2.4%) of whom developed postoperative respiratory failure. Backward stepwise logistic regression analysis revealed that age, body mass index, cardiovascular disease, diabetes, diffusion capacity of the lungs for carbon monoxide, tumour location and duration of chest surgery ≥101.5 min were predictive factors. A predictive model was constructed and showed acceptable performance (area under the curve: 0.755). The internal validation with the bootstrap method proves the good agreement for prediction and reality.

CONCLUSIONS

Obesity, severe diffusion dysfunction and upper segment oesophageal cancer were strong predictive factors. The established predictive model has acceptable predictive validity for postoperative respiratory failure after minimally invasive oesophagectomy, which may improve the identification of high-risk patients and enable health-care professionals to perform risk assessment for postoperative respiratory failure at the initial consultation.

Influence of the Oral Health Assessment Tool Score on Survival of Patients With Esophageal Cancer

BACKGROUND/AIM

We investigated the influence of the preoperative Oral Health Assessment Tool (OHAT) score on the outcomes of patients with esophageal cancer after curative surgery.

PATIENTS AND METHODS

This study included 90 patients with esophageal cancer who underwent curative surgery and who were screened with the OHAT between 2008 and 2021. The OHAT consists of eight categories with three possible scores. The risk factors for 5-year overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

Patients were divided into healthy (n=42) and unhealthy (n=48) groups. The OHAT score was identified as a significant risk factor for postoperative pneumonia (11.9% vs. 43.8%, p=0.001) and postoperative hospital stay (20.5 days vs. 50.1 days, p=0.042). The 5-year OS rate after surgery was 71.2% in the healthy group and 43.2% in the unhealthy group, which was a significant difference (p=0.015). A multivariate analysis showed that a high OHAT score was a significant independent factor for 5-year OS (p=0.034).

CONCLUSION

The OHAT score was a useful prognostic marker in patients who underwent curative surgery for esophageal cancer. To improve the oncological outcomes of patients with esophageal cancer, it is necessary to carefully plan perioperative oral/dental care using the OHAT score.

Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon

BACKGROUND

Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models.

METHODS

Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes.

RESULTS

Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models.

CONCLUSION

Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.

Preoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND

Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making.

AIM

To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness.

RESULTS

The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness.

CONCLUSION

Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.

Risk stratification for post-operative pulmonary complications following major cardiothoracic or abdominal surgery: Validation of the PPC Risk Prediction Score for physiotherapist's clinical decision-making

INTRODUCTION

Patients undergoing major cardiothoracic or abdominal surgery are at increased risk of developing post-operative pulmonary complications (PPC), but respiratory physiotherapy can prevent PPC. We have previously developed the PPC Risk Prediction Score to allocate physiotherapists' resources and stratify patients into three risk groups. In this study, we performed a temporal external validation of the PPC Risk Prediction Score. Such validation is rare and adds to the originality of this study.

METHODS

A cohort of 360 patients, admitted to undergo elective cardiothoracic or abdominal surgery, were included. Performance and clinical usefulness of the PPC Risk Prediction Score were estimated through discrimination, calibration and clinical usefulness, and the score was updated.

RESULTS

The score showed c-statistics of 0.62. Related to clinical usefulness, a cut point at 8 gave a sensitivity of 0.49 and a specificity of 0.70, whereas a cut point at 12 gave a sensitivity of 0.13 and a specificity of 0.95. Two predictors included in the development sample score, thoraco-abdominal incision odds ratio (OR) 2.74 (1.12;6.71) and sternotomy OR 2.09 (1.18;3.72), were statistically significantly associated to PPC in the validation sample.

CONCLUSIONS

The score was not able to discriminate between patients with and without PPC; neither was the updated score, but the study identified clinically relevant risk factors for developing PPC.

Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion

Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.

Risk Stratification for Postoperative Pulmonary Complications following Major Cardiothoracic and Abdominal Surgery - development of the PPC Risk Prediction Score for Physiotherapists Clinical Decision-making

INTRODUCTION

Major cardiothoracic or abdominal surgery can lead to the development of postoperative pulmonary complications (PPC), associated with increased morbidity and prolonged length of hospital stay. Preventive chest physiotherapy is routinely provided, but optimization of treatment strategies is needed to improve patient outcome and resource utilization.

OBJECTIVE

To develop a preoperative risk prediction scorelr to assist clinical decision-making regarding physiotherapy interventions.

METHODS

A prospective observational single-center study included 339 of 577 eligible patients admitted for major elective cardiothoracic or abdominal surgery. Primary outcome measure was PPC amendable to chest physiotherapy.

RESULTS

A total of 113 patients (33.3%) developed a PPC. Logistic regression modeling identified four independent predictors of PPC presented with odds ratio (OR) and 95% confidence interval. Reduced lung function (FEV₁ > 50% to <75% OR 2.4 (1.4; 4.3) and FEV₁ ≤ 50% OR 4.7 (1.4;16.0)), Recent unintended weight loss OR 4.5 (1.1; 18.7), Sternotomy OR 3.5 (2.0; 6.0) and Thoraco-abdominal incision OR 4.5 (2.1; 10.1). Based on assigned point values, a score dividing patients into three risk groups was developed. The score had moderate discrimination (c-statistic 0.70).

CONCLUSION

By following recommended guidelines (TRIPOD) a preoperative risk prediction score including four predictors of PPC was developed. External validation of the score is currently being investigated.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery.

METHODS

We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy).

RESULTS

46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry).

CONCLUSION

As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.

Preoperative maximum phonation time as a predictor of pneumonia in patients undergoing esophagectomy

PURPOSE

Esophagectomy is a highly invasive procedure, associated with several postoperative complications including pneumonia, anastomotic leakage, and sepsis, which may result in multiorgan failure. Pneumonia is considered a major predictor of poor long-term prognosis, so its prevention is important for patients undergoing surgery for esophageal cancer.

METHODS

The subjects of this study were 137 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January, 2012 and December, 2016. Patients who underwent R0 or R1 resection or esophagectomy with organ excision were included. Patients who underwent salvage surgery or resection of recurrent laryngeal nerve, and those with preoperative recurrent laryngeal nerve palsy, were excluded. We investigated the effect of the maximum phonation time on the development of postoperative pneumonia.

RESULTS

Pneumonia developed more frequently in patients with a long operative time, clinically left recurrent nerve lymph node metastasis, and a short preoperative maximum phonation time (p = 0.074, 0.046, and 0.080, respectively). Pneumonia was also more common in men with an abnormal maximum phonation time (p = 0.010).

CONCLUSIONS

The maximum phonation time is a significant predictor of postoperative pneumonia after esophagectomy in men.

A Scoring Tool That Identifies the Need for Positive-Pressure Ventilation and Determines the Effectiveness of Allocated Respiratory Therapy

BACKGROUND

Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV.

METHODS

Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV.

RESULTS

The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV (P < .001) and was associated with higher in-hospital mortality (P < .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV.

CONCLUSIONS

The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective.

Effect of the Active Cycle of Breathing Technique on Perioperative Outcome in Individuals With Esophagectomy: A Quasi-Experimental Study

Background: The effect of active cycle of breathing technique (ACBT) on EC patients has not been well elucidated. In this research, we aim to explore the effect of ACBT on the perioperative outcomes in patients with esophageal carcinoma who underwent esophagectomy. Methods: Patients who underwent esophagectomy in an academic institution from December 2017 to July 2019 were included in this study. In a quasi-experimental study, participants were randomly divided into an experimental group (active cycle of breathing technique, n = 107) and an observational group (n = 106) by drawing lots. The chi-squared test, Cochran-Mantel-Haenszel test, Logistic regression analysis, and Kruskal-Wallis test were used to analyze data. A two-sided P value <0.05 was considered statistically significant. The primary observational endpoint was the mean weight of the sputum. Other outcomes included the six-min-walk test (6MWT), Borg scale, anastomotic leakage, and the length of hospital stay. Results: 95 patients underwent minimally invasive surgery, and 118 patients received open surgery. There were 16 patients with anastomotic leakage in the present study, and we found that patients in the observational group had higher odds of anastomotic leakage. The results showed that the mean weight of the sputum in the observation group was lighter than that of the experimental group. After esophagectomy, the experimental group had better outcomes than the observation group (Borg scale: 2.448 vs. 1.547; 6-MWT: 372.811 vs. 425.355m, all P < 0.05). The mean length of hospital stay was longer in the observation group (17.953 days) than that in the experimental group (12.037 days, P = 0.01). We also found that the observational group had a higher discharge ratio over 2 weeks in all cohort (adjusted OR 2.487, 95% confidence intervals 1.147-5.392, P = 0.021). Conclusion: Active cycle of breathing technique may improve the perioperative outcomes and decrease the length of hospital stay after surgery in patients with esophageal cancer. However, we need more researches to validate these findings.

Preoperative maximal voluntary ventilation, hemoglobin, albumin, lymphocytes and platelets predict postoperative survival in esophageal squamous cell carcinoma

BACKGROUND

Preoperative pulmonary function plays an important role in selecting surgical candidates and assessing postoperative complications. Reduced pulmonary function is associated with poor survival in several cancers, but the prognostic value of preoperative pulmonary function in esophageal squamous cell carcinoma (ESCC) is unclear. Nutritional and systemic inflammation parameters are vital to cancer survival, and the combination of these parameters improves the prognostic value. The hemoglobin, albumin, lymphocytes and platelets (HALP) score is a novel prognostic indicator to reflect the nutritional and inflammation status, but the clinical effects of the HALP score combined with maximal voluntary ventilation (MVV), an important parameter of pulmonary function, have not been well studied in ESCC.

AIM

To investigate the prognostic value of MVV and HALP score for assessing postoperative survival of ESCC patients.

METHODS

Data from 834 ESCC patients who underwent radical esophagectomy with R0 resection were collected and retrospectively analyzed. Preoperative MVV and HALP data were retrieved from medical archives. The HALP score was calculated by the formula: Hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L)/platelets (/L). The optimal cut-off values of MVV and HALP score were calculated by the receiver operating characteristic curve analysis. The Kaplan-Meier method with log-rank test was used to draw the survival curves for the variables tested. Multivariate Cox proportional hazard regression models were used to analyze the independent prognostic factors for overall survival.

RESULTS

MVV was significantly associated with gender (P < 0.001), age at diagnosis (P < 0.001), smoking history (P < 0.001), drinking history (P < 0.001), tumor length (P = 0.013), tumor location (P = 0.037) and treatment type (P = 0.001). The HALP score was notably associated with gender (P < 0.001), age at diagnosis (P = 0.035), tumor length (P < 0.001) and invasion depth (P = 0.001). Univariate Cox regression analysis showed that low MVV and low HALP score were associated with worse overall survival (all P < 0.001). Multivariate analysis showed that low MVV and the HALP score were both independent risk factors for overall survival (all P < 0.001). The combination of MVV and HALP score improved the prediction performance for overall survival than tumor-node-metastasis. Also, low combination of MVV and HALP score was an independent risk factor for poor overall survival (P < 0.001).

CONCLUSION

MVV, HALP score and their combination are simple and promising clinical markers to predict overall survival of ESCC patients.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study

OBJECTIVES

Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy.

DESIGN

Retrospective cohort study (level 3 evidence).

SETTING

Tertiary care referral center.

PARTICIPANTS

Patients who underwent esophagectomy from 2007 to 2017.

INTERVENTIONS

The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h).

MEASUREMENTS

Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use.

MAIN RESULTS

A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified.

CONCLUSIONS

Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Prevention of post-operative complications by using a HMG-CoA reductase inhibitor in patients undergoing one-lung ventilation for non-cardiac surgery: study protocol for a randomised controlled trial

Background

Postoperative pulmonary complications (PPC) and peri-operative myocardial infarction (MI) have a significant impact on the long-term mortality of surgical patients. Patients undergoing one-lung ventilation (OLV) for surgery are at a high risk of developing these complications. These complications could be associated with intensive care unit (ICU) admissions and longer hospital stay with associated resource and economic burden. Simvastatin, a HMG-CoA reductase enzyme inhibitor has been shown to have pleiotropic anti-inflammatory effects as well as being endothelial protective. The benefits of statins have been shown in various observational studies and in small proof-of-concept studies. There is an urgent need for a well-designed, large clinical trial powered to detect clinical outcomes. The Prevention HARP 2 trial will test the hypothesis ‘simvastatin 80 mg when compared to placebo will reduce cardiac and pulmonary complications in patients undergoing elective oesophagectomy, lobectomy or pneumonectomy’.

Methods/design

The Prevention HARP 2 trial is a UK multi-centre, randomised, double-blind, placebo-controlled trial. Adult patients undergoing elective oesophagectomy, lobectomy or pneumonectomy will be eligible. Patients who are already on statins will be excluded from this trial. Patients will be randomised to receive simvastatin 80 mg or matched placebo for 4 days pre surgery and for up to 7 days post surgery. The primary outcome is a composite outcome of PPC and MI within 7 days post surgery. Various secondary outcome measures including clinical outcomes, safety outcomes and health economic outcomes will be collected. The study aims to recruit 452 patients in total across 12 UK sites.

Discussion

The results of the Prevention HARP 2 trial should add to our understanding of the benefits of peri-operative statins and influence clinical decision-making. Analysis of blood and urine samples from the patients will provide insight into the mechanism of simvastatin action.

Trial registration

International Standard Randomised Controlled Trials registry, ID: ISRCTN48095567. Registered on 11 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3078-5) contains supplementary material, which is available to authorized users.

Spirometric Lung Age Predicts Postoperative Pneumonia After Esophagectomy

BACKGROUND

Despite advances in treatment, postoperative pneumonia remains a major problem after esophagectomy. Lung age has been proposed as a comprehensive indicator for respiratory function. The aim of this study is to reveal the efficacy of lung age in predicting occurrence of pneumonia after esophagectomy.

METHODS

We assessed 342 consecutive patients who underwent subtotal esophagectomy for primary esophageal cancer from 2011 to 2014. Lung age was calculated from the preoperative spirometric test using the methods advocated by the Japanese Respiratory Society. We investigated factors predicting the occurrence of postoperative pneumonia after esophagectomy.

RESULTS

The incidence of postoperative pneumonia was 28.9 %. According to the Clavien-Dindo classification, grade II and grade III-V pneumonia were observed in 21.3 and 7.6 % patients, respectively. In multivariate logistic regression analysis for the factors predicting the occurrence of postoperative pneumonia, higher lung age (p = 0.010) and lower body mass index (p = 0.006) were independent factors. Patients with grade III-V pneumonia tended to have higher lung age than those with grade II pneumonia (p = 0.084). In addition, lung age was significantly higher in patients who experienced pneumonia within postoperative days 7 than those who experienced pneumonia after postoperative days 7 (p = 0.028).

CONCLUSION

Spirometric lung age was associated with occurrence, severity, and time of onset of postoperative pneumonia after esophagectomy. This simple parameter deserves a greater consideration as a predictor of postoperative pneumonia after esophagectomy and can support both surgeons and patients in understanding the status of respiratory function.

Current treatment options for esophageal diseases

Exciting new developments-pharmacologic, endoscopic, and surgical-have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barrett's esophagus, since a recent meta-analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot-assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity.

Assessment of a predictive score for pulmonary complications in cancer patients after esophagectomy

BACKGROUND

Esophagectomy is a very important method for the treatment of resectable esophageal cancer, which carries a high rate of morbidity and mortality. This study was undertaken to assess the predictive score proposed by Ferguson et al for pulmonary complications after esophagectomy for patients with cancer.

METHODS

The data of patients who admitted to the intensive care unit after transthoracic esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between September 2008 and October 2010 were retrospectively reviewed.

RESULTS

Two hundred and seventeen patients were analyzed and 129 (59.4%) of them had postoperative pulmonary complications. Risk scores varied from 0 to 12 in all patients. The risk scores of patients with postoperative pulmonary complications were higher than those of patients without postoperative pulmonary complications (7.27±2.50 vs. 6.82±2.67; P=0.203). There was no significant difference in the incidence of postoperative pulmonary complications as well as in the increase of risk scores (χ (2)=5.477, P=0.242). The area under the curve of predictive score was 0.539±0.040 (95%CI 0.461 to 0.618; P=0.324) in predicting the risk of pulmonary complications in patients after esophagectomy.

CONCLUSION

In this study, the predictive power of the risk score proposed by Ferguson et al was poor in discriminating whether there were postoperative pulmonary complications after esophagectomy for cancer patients.

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.