Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database

The anastomotic leak triad: preoperative patient characteristics, intraoperative risk factors, and postoperative outcomes

BACKGROUND

The aim of this study was to determine perioperative risk factors associated with anastomotic leak (AL) after minimally invasive esophagectomy (MIE) and its association with cancer recurrence and overall survival.

METHODS

This retrospective observational study of electronic health record data included patients who underwent MIE for esophageal cancer between September 2013 and July 2023 at a tertiary center. The primary outcome was AL after esophagectomy, whereas the secondary outcomes included time to cancer recurrence and overall survival. Perioperative patient factors were evaluated to determine their associations with the primary and the secondary outcomes. Propensity score-matched logistic regression assessed the associations between perioperative factors and AL. Kaplan-Meier survival curves compared cancer recurrence and overall survival by AL.

RESULTS

A total of 251 consecutive patients with esophageal cancer were included in the analysis; 15 (6%) developed AL. Anemia, hospital complications, hospital length of stay, and 30-day readmissions significantly differed from those with and without AL (P = .037, <.001, <.001, and.016, respectively). Moreover, 30- and 90-day mortality were not statistically affected by the presence of AL (P = .417 and 0.456, respectively). Logistic regression modeling showed drug history and anemia were significantly associated with AL (P = .022 and.011, respectively). The presence of AL did not significantly impact cancer recurrence or overall survival (P = .439 and.301, respectively).

CONCLUSION

The etiology of AL is multifactorial. Moreover, AL is significantly associated with drug history, preoperative anemia, hospital length of stay, and 30-day readmissions, but it was not significantly associated with 30- or 90-day mortality, cancer recurrence, or overall survival. Patients should be optimized before undergoing MIE with special consideration for correcting anemia. Ongoing research is needed to identify more modifiable risk factors to minimize AL development and its associated morbidity.

Contemporary outcomes of left thoraco-abdominal esophagectomy due to cancer in the esophagus or gastroesophageal junction, a multicenter cohort study

Surgery for cancer of the esophagus or gastro-esophageal junction can be performed with a variety of minimally invasive and open approaches. The left thoracoabdominal esophagectomy (LTE) is an open technique that gives an opportunity to operate in the chest and abdomen with excellent exposure of the gastro-esophageal junction through a single incision, and there is currently no equivalent minimally invasive technique available. The aim of this multi-institutional review was to study a large contemporary international study cohort of patients treated with LTE. An international multicenter cohort study was performed including all patients treated with LTE at six high-volume centers for gastro-esophageal cancer surgery between 2012 and 2022. Patient data were prospectively collected in each participating centers' institutional database. Information about patient, tumor, and treatment details were collected. The study cohort included a total of 793 patients treated with LTE during the study period. The most frequently observed complications were pneumonia in 185/727 (25.5%) patients and atrial fibrillation in 91/727 (12.5%). Anastomotic leak occurred in 35/727 (4.8%) patients; no patient suffered from conduit necrosis. Thirty-day mortality occurred in 15/785 (1.9%) patients and 90-day mortality in 39/785 (5.0%) patients. Factors with statistically significant association with survival were American Society for Anesthesiologists-score, tumor location, tumor stage, and tumor free resection margins. Neoadjuvant therapy was not associated with increased survival compared to surgery alone but neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy showed statistically significant improved survival with hazard ratio 0.60 (95% confidence intervals:0.44-0.80, P = 0.001) in a multivariable adjusted model. This study demonstrates that LTE can be applied in selected patients with results that are comparable to other large studies of open and minimally invasive surgery for esophageal or gastro-esophageal cancer at high-volume centers.

Reasons for fear of cancer recurrence after endoscopic treatment of T1 esophageal adenocarcinoma. A semi-structured interview study

Prior research has shown that patients with early Barrett's neoplasia treated endoscopically report at least the same level of fear for cancer recurrence as patients treated surgically for a more advanced disease stage. The aim of this qualitative study was to gain insight into the reasons why endoscopically treated patients fear or not fear cancer recurrence. Patients treated endoscopically for T1 esophageal adenocarcinoma participated in a semi-structured interview. Patients were asked open questions about their fear of cancer recurrence and presented an a priori list of possible reasons for experiencing or not experiencing fear of cancer recurrence. Data saturation was reached with 12 patients who added 7 new reasons. Reasons that induced fear of cancer recurrence were related to physical symptoms, if cancer was diagnosed as an accidental finding and experiences with cancer in close relations. Endoscopic surveillance was mentioned as a reason for not experiencing fear of cancer recurrence. Patients reduced their fear of cancer recurrence by talking to close relations and seeking distraction. Caregivers reduced patients fear of cancer recurrence by giving adequate information and by showing photo of the treatment and the results of the treatment. According to patients with early Barrett's neoplasia, receiving comprehensible information about the risk of recurrence and potential symptoms that may or may not be indicative of cancer recurrence, and continuing endoscopic surveillance, reduced fear of cancer recurrence. We recommend that healthcare providers discuss fear of cancer recurrence with their patients to enable tailoring information provision to their needs.

Recurrence and Survival After Minimally Invasive and Open Esophagectomy for Esophageal Cancer: A Post Hoc Analysis of the Ensure Study

OBJECTIVE

To determine the impact of operative approach [open (OE), hybrid minimally invasive (HMIE), and total minimally invasive (TMIE) esophagectomy] on operative and oncologic outcomes for patients treated with curative intent for esophageal and junctional cancer.

BACKGROUND

The optimum oncologic surgical approach to esophageal and junctional cancer is unclear.

METHODS

This secondary analysis of the European multicenter ENSURE study includes patients undergoing curative-intent esophagectomy for cancer between 2009 and 2015 across 20 high-volume centers. Primary endpoints were disease-free survival (DFS) and the incidence and location of disease recurrence. Secondary endpoints included among others R0 resection rate, lymph node yield, and overall survival (OS).

RESULTS

In total, 3199 patients were included. Of these, 55% underwent OE, 17% HMIE, and 29% TMIE. DFS was independently increased post-TMIE [hazard ratio (HR): 0.86 (95% CI: 0.76-0.98), P = 0.022] compared with OE. Multivariable regression demonstrated no difference in absolute locoregional recurrence risk according to the operative approach [HMIE vs OE, odds ratio (OR): 0.79, P = 0.257; TMIE vs OE, OR: 0.84, P = 0.243]. The probability of systemic recurrence was independently increased post-HMIE (OR: 2.07, P = 0.031), but not TMIE (OR: 0.86, P = 0.508). R0 resection rates ( P = 0.005) and nodal yield ( P < 0.001) were independently increased after TMIE, but not HMIE ( P = 0.424; P = 0.512) compared with OE. OS was independently improved following both HMIE (HR: 0.79, P = 0.009) and TMIE (HR: 0.82, P = 0.003) as compared with OE.

CONCLUSION

In this European multicenter study, TMIE was associated with improved surgical quality and DFS, whereas both TMIE and HMIE were associated with improved OS as compared with OE for esophageal cancer.

Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial)

BACKGROUND

Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN.

METHODS

Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes.

RESULTS

From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths.

CONCLUSION

In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).

Root cause analysis of mortality after esophagectomy for cancer: a multicenter cohort study from the FREGAT database

BACKGROUND

Esophagectomy is associated with significant mortality. A better understanding of the causes leading to death may help to reduce mortality. A root cause analysis of mortality after esophagectomy was performed.

METHODS

Root cause analysis was retrospectively applied by an independent expert panel of 4 upper gastrointestinal surgeons and 1 anesthesiologist-intensivist to patients included in the French national multicenter prospective cohort FREGAT between August 2014 and September 2019 who underwent an esophagectomy for cancer and died within 90 days of surgery. A cause-and-effect diagram was used to determine the root causes related to death. Death was classified as potentially preventable or non-preventable.

RESULTS

Among the 1,040 patients included in the FREGAT cohort, 70 (6.7%) patients (male: 81%, median age 68 [62-72] years) from 17 centers were included. Death was potentially preventable in 37 patients (53%). Root causes independently associated with preventable death were inappropriate indication (odds ratio 35.16 [2.50-494.39]; P = .008), patient characteristics (odds ratio 5.15 [1.19-22.35]; P = .029), unexpected intraoperative findings (odds ratio 18.99 [1.07-335.55]; P = .045), and delay in diagnosis of a complication (odds ratio 98.10 [6.24-1,541.04]; P = .001). Delay in treatment of a complication was found only in preventable deaths (28 [76%] vs 0; P < .001). National guidelines were less frequently followed (16 [43%] vs 22 [67%]; P = .050) in preventable deaths. The only independent risk factor of preventable death was center volume <26 esophagectomies per year (odds ratio 4.71 [1.55-14.33]; P = .006).

CONCLUSIONS

More than one-half of deaths after esophagectomy were potentially preventable. Better patient selection, early diagnosis, and adequate management of complications through centralization could reduce mortality.

VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review

Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.

Ultrabright NIR-IIb Fluorescence Quantum Dots for Targeted Imaging-Guided Surgery

Pioneering approaches for precise tumor removal involve fluorescence-guided surgery, while challenges persist, including the low fluorescence contrast observed at tumor boundaries and the potential for excessive damage to normal tissue at the edges. Lead/cadmium sulfide quantum dots (PbS@CdS QDs), boasting high quantum yields (QYs) and vivid fluorescence, have facilitated advancements in the second near-infrared window (NIR-II, 900-1700 nm). However, during fluorescent surgical navigation operations, hydrophilic coatings of these inorganic nanoparticles (NPs) guarantee biosafety; it also comes at the expense of losing a significant portion of QY and NIR-II fluorescence, causing heightened damage to normal tissues caused by cutting edges. Herein, we present hydrophilic core-shell PbS@CdS@PEG NPs with an exceptionally small diameter (∼8 nm) and a brilliant NIR-IIb (1500-1700 nm) emission at approximately 1600 nm. The mPEG-SH (MW: 2000) addresses the hydrophobicity and enhances the biosafety of PbS@CdS QDs. In vivo fluorescence-guided cervical tumor resection becomes achievable immediately upon injection of an aqueous solution of PbS@CdS@PEG NPs. Notably, this approach results in a significantly reduced thickness (100-500 μm) of damage to normal tissues at the margins of the resected tumors. With a high QY (∼30.2%) and robust resistance to photobleaching, NIR-IIb imaging is sustained throughout the imaging process.

Impact of pulmonary complications following esophagectomy on long-term survival: multivariate meta-analysis and restricted mean survival time assessment

Pulmonary complications (PC) are common after esophagectomy and their impact on long-term survival is not defined yet. The present study aimed to assess the effect of postoperative PCs on long-term survival after esophagectomy for cancer. Systematic review of the literature through February 1, 2023, was performed. The included studies evaluated the effect of PC on long-term survival. Primary outcome was long-term overall survival (OS). Cancer-specific survival (CSS) and disease-free survival (DFS) were secondary outcomes. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. Eleven studies were included (3423 patients). Overall, 674 (19.7%) patients developed PC. The RMSTD analysis shows that at 60-month follow-up, patients not experiencing PC live an average of 8.5 (95% CI 6.2-10.8; p < 0.001) months longer compared with those with PC. Similarly, patients not experiencing postoperative PC seem to have significantly longer CSS (8 months; 95% CI 3.7-12.3; p < 0.001) and DFS (5.4 months; 95% CI 1.6-9.1; p = 0.005). The time-dependent HRs analysis shows a reduced mortality hazard in patients without PC at 12 (HR 0.6, 95% CI 0.51-0.69), 24 (HR 0.64, 95% CI 0.55-0.73), 36 (HR 0.67, 95% CI 0.55-0.79), and 60 months (HR 0.69, 95% CI 0.51-0.89). This study suggests a moderate clinical impact of PC on long-term OS, CSS, and DFS after esophagectomy. Patients not experiencing PC seem to have a significantly reduced mortality hazard up to 5 years of follow-up.

Early postoperative endoscopy for predicting anastomotic leakage after minimally invasive esophagectomy: A large-volume retrospective study

BACKGROUND

Anastomotic leakage is one of the most severe adverse events of minimally invasive esophagectomy for esophageal cancer. Early postoperative endoscopy is considered to be the most objective means to diagnose anastomotic leakage, but its safety is questioned by clinicians. This study aimed to evaluate the safety and effectiveness of early postoperative endoscopy in predicting anastomotic leakage.

METHODS

Patients who underwent minimally invasive esophagectomy (from January 2017 to June 2021) in our center were identified and divided into early postoperative endoscopy and control groups according to whether they underwent early postoperative endoscopy within 72 hours after surgery. Propensity score matching was used to balance baseline characteristics. The incidence of postoperative adverse events was compared between the 2 groups, risk variables for anastomotic leakage were identified using logistic regression, and abnormal endoscopic findings related to anastomotic leakage occurrence were explored.

RESULTS

A total of 436 patients were enrolled, of whom 134 underwent early postoperative endoscopy. One hundred and thirty-two pairs were matched by propensity score matching, and baseline characteristics were well-balanced. Both before and after propensity score matching, early postoperative endoscopy did not increase the incidence of postoperative adverse events (chyle leak, hypoproteinemia, pneumonia, etc) and in-hospital mortality. Notably, the incidence of anastomotic leakage (9.8% vs 22.7%) and the length of mean postoperative hospital stay (17.6 vs 20.9 days) was significantly decreased in the early postoperative endoscopy group. Finally, based on the findings under early postoperative endoscopy, we found that gastric graft ischemia is related to a higher incidence of anastomotic leakage (P = .023).

CONCLUSION

Early postoperative endoscopy does not increase postoperative adverse events after minimally invasive esophagectomy and may guide early prediction and intervention strategies for anastomotic leakage in patients undergoing minimally invasive esophagectomy.

Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance

OBJECTIVE

Chemoradiation followed by esophagectomy is a standard treatment option for patients with locally advanced esophageal cancer (LAEC). Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT).

METHODS

Decision analysis with Markov modeling was used. The base case was a 60-year-old man with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modeled for a 5-year time horizon. Primary outcomes were life-years and quality-adjusted life-years (QALY). Probabilities and utilities were derived through the literature. Deterministic sensitivity analyses were performed using ranges from the literature with consideration for clinical plausibility.

RESULTS

Surgery was favored for survival with an expected life-years of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favored, with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318), and disutility of previous esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality.

CONCLUSIONS

Our study finds that surgery increases life expectancy but decreases QALY. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan

OBJECTIVE

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy.

BACKGROUND

CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria.

METHODS

Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses.

RESULTS

Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results.

CONCLUSIONS

The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer

Esophagectomy is an exemplar of complex oncological surgery and is associated with a relatively high risk of major morbidity and mortality. In the modern era, where specific complications are targeted in prevention and treatment pathways, and where the principles of enhanced recovery after surgery are espoused, optimum outcomes are targeted via a number of approaches. These include comprehensive clinical and physiological risk assessment, specialist perioperative care by a high-volume team, and multimodal inputs throughout the patient journey that aim to preserve or restore nutritional deficits, muscle mass and function.

National outcomes of expedited discharge following esophagectomy for malignancy

BACKGROUND

Expedited discharge following esophagectomy is controversial due to concerns for higher readmissions and financial burden. The present study aimed to evaluate the association of expedited discharge with hospitalization costs and unplanned readmissions following esophagectomy for malignant lesions.

METHODS

Adults undergoing elective esophagectomy for cancer were identified in the 2014-2019 Nationwide Readmissions Database. Patients discharged by postoperative day 7 were considered Expedited and others as Routine. Patients who did not survive to discharge or had major perioperative complications were excluded. Multivariable regression models were constructed to assess association of expedited discharge with index hospitalization costs as well as 30- and 90-day non-elective readmissions.

RESULTS

Of 9,886 patients who met study criteria, 34.6% comprised the Expedited cohort. After adjustment, female sex (adjusted odds ratio [AOR] 0.71, p = 0.001) and increasing Elixhauser Comorbidity Index (AOR 0.88/point, p<0.001) were associated with lower odds of expedited discharge, while laparoscopic (AOR 1.63, p<0.001, Ref: open) and robotic (AOR 1.67, p = 0.003, Ref: open) approach were linked to greater likelihood. Patients at centers in the highest-tertile of minimally invasive esophagectomy volume had increased odds of expedited discharge (AOR 1.52, p = 0.025, Ref: lowest-tertile). On multivariable analysis, expedited discharge was independently associated with an $8,300 reduction in hospitalization costs. Notably, expedited discharge was associated with similar odds of 30-day (AOR 1.10, p = 0.40) and 90-day (AOR 0.90, p = 0.70) unplanned readmissions.

CONCLUSION

Expedited discharge after esophagectomy was associated with decreased costs and unaltered readmissions. Prospective studies are necessary to robustly evaluate whether expedited discharge is appropriate for select patients undergoing esophagectomy.

The effect of aging on short- and long-term results after esophagectomy: an international multicenter retrospective analysis

The optimal treatment for esophageal cancer in elderly patients is still debated and data on postoperative results are limited. This retrospective international study aims to clarify the impact of age on clinical and oncological outcomes after esophagectomy. All patients that underwent esophagectomy for cancer between 2007 and 2016 at two European high-volume Centers have been included in the study. Patients were divided into three groups according to their age: young-age group (YAG) (18-69), middle-age group (70-74) and old-age group (>74). Primary outcome was 5-year overall survival (OS), while secondary outcomes considered were 5-year disease free survival and disease related survival, 90-day morbidity and mortality, readmission rate and radicality. A total of 575 patients were included. No differences emerged in terms of morbidity and length of stay, while mortality increased with aging from 2% in YAG to 4.8% in old-aged (P = 0.003). Old-age patients had less neoadjuvant treatment (P < 0.001), a less aggressive mediastinal lymphadenectomy and presented a more advanced pathological stage. As expected, OS decreased significantly for older patients compared with the other two age groups (P = 0.044) but, on the other hand, disease free and disease related survival were comparable between the groups. Age itself should not be considered a contraindication to esophagectomy. Although in patients older than 75 years postoperative mortality is significantly increased, esophagectomy could be still an option in selected patients, favoring the use of minimally invasive techniques and enhanced recovery protocols.

Survival Impacts of Impaired Lung Functions and Comorbidities on Elderly Esophageal Cancer Patients

BACKGROUND

Preoperative physiological assessments are crucial for optimizing clinical outcomes, especially those of elderly esophageal cancer (EC) patients who are generally frail and at the high risk of mortality.

METHODS

Patients who underwent surgery for EC between 2004 and 2018 were retrospectively reviewed. Patients were categorized into elderly (>70 years) or non-elderly (≤70 years) groups. Various physiological parameters including the Charlson Comorbidity Index (CCI), immunonutritional parameters and pulmonary functions were studied. Pulmonary functions included %vital capacity (VC) and forced expiratory volume in one second (FEV1.0) and FEV1.0%. The thresholds were set as the lowest quartile (100% for %VC and 2L for FEV1.0) in this cohort. Multivariate Cox hazards models were applied to determine independent predictors of non-EC-related deaths.

RESULTS

In total, 824 patients were included (elderly; n = 306, non-elderly; n = 518). Elderly patients had a significantly lower 5-year OS rate than non-elderly patients (53.3% vs. 57.2%, P = 0.03), mainly due to increased risk of death from non-EC related causes. In the elderly group, multivariate Cox hazards analysis identified 3 independent predictors of non-EC-related deaths; high CCI (HR 1.98, P=0.006), low %VC (HR 2.01, P = 0.004) and low FEV1.0 (HR 1.6, P=0.048). Elderly patients without risk factors had a significantly better 5-year OS rate (63.5%) than those with 1 (50.0%) or 2-3 (36.3%) risk factors (P <0.01). Deaths due to pulmonary disease rose significantly as the number of risk factors increased (P=0.03).

CONCLUSIONS

The severity of comorbidities and pulmonary function impairments are useful for predicting long-term outcomes, especially non-EC-related deaths, in elderly EC patients.

Incidence and Impact of Preoperative Hiatal Hernia in Patients with Esophageal Carcinoma Undergoing Curative Surgical Resection

BACKGROUND

Hiatal hernia (HH) and gastroesophageal reflux disease (GERD) are risk factors for esophageal adenocarcinoma. High positive margin rates and poor survival were described among HH patients undergoing esophagectomy. We sought to describe incidence and impact of HH on outcomes following esophagectomy.

METHODS

Patients who underwent esophagectomy 2012-2019 for esophago-junctional carcinoma were included. CT studies were blindly reviewed by two radiologists. A third radiologist reviewed cases of disagreement. Hernias ≥ 3 cm were included in the HH group.

RESULTS

Overall, 66 patients (33%) had HH ≥ 3 cm. The no hernia group included 12 patients (6%) with < 3 cm HH and 106 (53%) without HH. Preoperative variables were comparable among groups. Location of anastomosis was similar among cohorts and predominantly cervical (n = 97, 82.2% vs 61, 92.4%, p = 0.113). Postoperatively, HH patients had higher incidence of atrial dysrhythmia (n = 11, 16.7% vs n = 6, 5.1% p = 0.015). Rates of R0 resections were similar (n = 62, 93.9%, vs n = 113, 95.8%, p = 0.724). HH patients had higher rates of signet ring cell histology (n = 14, 21.2% vs n = 9, 7.6% p = 0.025); this was confirmed on subgroup analysis including only adenocarcinoma patients (n = 14, 28.6% vs n = 8, 12.3%, p = 0.042). On Cox regression analysis, HH was not associated with disease-free or overall survival (HR 1.308, p = 0.274 and HR .905, p = 0.722).

CONCLUSIONS

Patients with preoperative HH had higher rates of postoperative atrial dysrhythmias and signet ring cell features on pathology. In a population with predominant cervical anastomosis, positive margin rates were low and survival comparable among cohorts.

Left thoracoabdominal oesophagectomy: contemporary update on technique and outcomes

This contemporary guide to left thoracoabdominal oesophagectomy details the surgical aspects, surgical considerations, and outcomes from the two largest centres in the world that perform this procedure. The left thoracoabdominal approach increases the potential for negative resection margins in distal oesophageal, junctional, and cardial cancers. High-volume oesophageal centres should consider including the left thoracoabdominal approach in their operative options and ensure that their trainees are exposed to this unique approach to oesophagogastric resections.

The impact of intraoperative and postoperative fluid balance on complications for transthoracic esophagectomy: a retrospective analysis

OBJECTIVE

Transthoracic esophagectomy is associated with significant morbidity and mortality. Therefore, it is imperative to optimize perioperative management and minimize complications. In this retrospective analysis, we evaluated the association between fluid balance and esophagectomy complications at a tertiary hospital in Melbourne, Australia, with a particular focus on respiratory morbidity and anastomotic leaks. Cumulative fluid balance was calculated intraoperatively, postoperatively in recovery postoperative day (POD) 0, and on POD 1 and 2. High and low fluid balance was defined as greater than or less than the median fluid balance, respectively, and postoperative surgical complications were graded using the Clavien-Dindo classification.

RESULTS

In total, 109 patients, with an average age of 64 years, were included in this study. High fluid balance on POD 0, POD1 and POD 2 was associated with a higher incidence of anastomotic leak (OR 8.59; 95%CI: 2.64-39.0). High fluid balance on POD 2 was associated with more severe complications (of any type) (OR 3.33; 95%CI: 1.4-8.26) and severe pulmonary complications (OR 3.04; 95%CI: 1.27-7.67). For every 1 L extra cumulative fluid balance in POD 1, the odds of a major complication increase by 15%, while controlling for body mass index (BMI) and American Society of Anaesthesiologists (ASA) class. The results show that higher cumulative fluid balance is associated with worsening postoperative outcomes in patients undergoing transthoracic esophagectomy. Restricted fluid balance, especially postoperatively, may mitigate the risk of postoperative complications - however prospective trials are required to establish this definitively.

Trimodality therapy versus perioperative chemotherapy in the management of locally advanced adenocarcinoma of the oesophagus and oesophagogastric junction (Neo-AEGIS): an open-label, randomised, phase 3 trial

BACKGROUND

The optimum curative approach to adenocarcinoma of the oesophagus and oesophagogastric junction is unknown. We aimed to compare trimodality therapy (preoperative radiotherapy with carboplatin plus paclitaxel [CROSS regimen]) with optimum contemporaneous perioperative chemotherapy regimens (epirubicin plus cisplatin or oxaliplatin plus fluorouracil or capecitabine [a modified MAGIC regimen] before 2018 and fluorouracil, leucovorin, oxaliplatin, and docetaxel [FLOT] subsequently).

METHODS

Neo-AEGIS (CTRIAL-IE 10-14) was an open-label, randomised, phase 3 trial done at 24 centres in Europe. Patients aged 18 years or older with clinical tumour stage T2-3, nodal stage N0-3, and M0 adenocarcinoma of the oesophagus and oesophagogastric junction were randomly assigned to perioperative chemotherapy (three preoperative and three postoperative 3-week cycles of intravenous 50 mg/m2 epirubicin on day 1 plus intravenous 60 mg/m2 cisplatin or intravenous 130 mg/m2 oxaliplatin on day 1 plus continuous infusion of 200 mg/m2 fluorouracil daily or oral 625 mg/m2 capecitabine twice daily up to 2018, with four preoperative and four postoperative 2-week cycles of 2600 mg/m2 fluorouracil, 85 mg/m2 oxaliplatin, 200 mg/m2 leucovorin, and 50 mg/m2 docetaxel intravenously on day 1 as an option from 2018) or trimodality therapy (41·4 Gy in 23 fractions on days 1-5, 8-12, 15-19, 22-26, and 29-31 with intravenous area under the curve 2 mg/mL per min carboplatin plus intravenous 50 mg/m2 paclitaxel on days 1, 8, 15, 22, and 29). The primary endpoint was overall survival, assessed in all randomly assigned patients who received at least one dose of study drug, regardless of which study drug they received, by intention to treat. Secondary endpoints were disease-free survival, site of treatment failure, operative complications, toxicity, pathological response (complete [ypT0N0] and major [tumour regression grade 1 and 2]), margin-free resection (R0), and health-related quality of life. Toxicity and safety data were analysed in the safety population, defined as patients who took at least one dose of study drug, according to treatment actually received. The initial power calculation was based on superiority of trimodality therapy (n=366 patients); it was adjusted after FLOT became an option to a non-inferiority design with a margin of 5% for perioperative chemotherapy (n=540). This study is registered with ClinicalTrials.gov, NCT01726452.

FINDINGS

Between Jan 24, 2013, and Dec 23, 2020, 377 patients were randomly assigned, of whom 362 were included in the intention-to treat population (327 [90%] male and 360 [99%] White): 184 in the perioperative chemotherapy group and 178 in the trimodality therapy group. The trial closed prematurely in December, 2020, after the second interim futility analysis (143 deaths), on the basis of similar survival metrics and the impact of the COVID-19 pandemic. At a median follow-up of 38·8 months (IQR 16·3-55·1), median overall survival was 48·0 months (95% CI 33·6-64·8) in the perioperative chemotherapy group and 49·2 months (34·8-74·4) in the trimodality therapy group (3-year overall survival 55% [95% CI 47-62] vs 57% [49-64]; hazard ratio 1·03 [95% CI 0·77-1·38]; log-rank p=0·82). Median disease-free survival was 32·4 months (95% CI 22·8-64·8) in the perioperative chemotherapy group and 24·0 months (18·0-40·8) in the trimodality therapy group [hazard ratio 0·89 [95% CI 0·68-1·17]; log-rank p=0·41). The pattern of recurrence, locoregional or systemic, was not significantly different (odds ratio 1·35 [95% CI 0·63-2·91], p=0·44). Pathological complete response (odds ratio 0·33 [95% CI 0·14-0·81], p=0·012), major pathological response (0·21 [0·12-0·38], p<0·0001), and R0 rates (0·21 [0·08-0·53], p=0·0003) favoured trimodality therapy. The most common grade 3-4 adverse event was neutropenia (49 [27%] of 183 patients in the perioperative chemotherapy group vs 11 [6%] of 178 patients in the trimodality therapy group), followed by diarrhoea (20 [11%] vs none), and pulmonary embolism (ten [5%] vs nine [5%]). One (1%) patient in the perioperative chemotherapy group and three (2%) patients in the trimodality therapy group died from serious adverse events, two (one in each group) of which were possibly related to treatment. No differences were seen in operative mortality (five [3%] deaths in the perioperative chemotherapy group vs four [2%] in the trimodality therapy group), major morbidity, or in global health status at 1 and 3 years.

INTERPRETATION

Although underpowered and incomplete, Neo-AEGIS provides the largest comprehensive randomised dataset for patients with adenocarcinoma of the oesophagus and oesophagogastric junction treated with perioperative chemotherapy (predominantly the modified MAGIC regimen), and CROSS trimodality therapy, and reports similar 3-year survival and no major differences in operative and health-related quality of life outcomes. We suggest that these data support continued clinical equipoise.

FUNDING

Health Research Board, Cancer Research UK, Irish Cancer Society, Oesophageal Cancer Fund, and French National Cancer Institute.

Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

The proportion of early extubation after esophagectomy varies among hospitals; however, the impact on clinical outcomes is unclear. The aim of this retrospective study was to evaluate associations between the proportion of early extubation in hospitals and short-term outcomes after esophagectomy. Because there is no consensus regarding the optimal timing for extubation, the authors considered that hospitals' early extubation proportion reflects the hospital-level extubation strategy.

MATERIALS AND METHODS

Data of patients who underwent oncologic esophagectomy (July 2010-March 2019) were extracted from a Japanese nationwide inpatient database. The proportion of patients who underwent early extubation (extubation on the day of surgery) at each hospital was assessed and grouped by quartiles: very low- (<11%), low- (11-37%), medium- (38-83%), and high-proportion (≥84%) hospitals. The primary outcome was respiratory complications; secondary outcomes included reintubation, anastomotic leakage, other major complications, and hospitalization costs. Multivariable regression analyses were performed, adjusting for patient demographics, cancer treatments, and hospital characteristics. A restricted cubic spline analysis was also performed for the primary outcome.

RESULTS

Among 37 983 eligible patients across 545 hospitals, early extubation was performed in 17 931 (47%) patients. Early extubation proportions ranged from 0-100% across hospitals. Respiratory complications occurred in 10 270 patients (27%). Multivariable regression analyses showed that high- and medium-proportion hospitals were significantly associated with decreased respiratory complications [odds ratio, 0.46 (95% CI, 0.36-0.58) and 0.43 (0.31-0.60), respectively], reintubation, and hospitalization costs when compared with very low-proportion hospitals. The risk of anastomotic leakage and other major complications did not differ among groups. The restricted cubic spline analysis demonstrated a significant inverse dose-dependent association between the early extubation proportion and the risk of respiratory complications.

CONCLUSION

A higher proportion of early extubation in a hospital was associated with a lower occurrence of respiratory complications, highlighting a potential benefit of early extubation after esophagectomy.

Impact of Morbid Obesity on Post-esophagectomy Leak Rate: a NSQIP Analysis

BACKGROUND

Morbid obesity is becoming more prevalent and is a known risk factor for esophageal cancer. Esophagectomy in this population is technically more challenging than the non-obese, thus increasing the risks of surgery. This study hypothesizes that higher body mass index (BMI) is associated with higher anastomotic leak rates after esophagectomy.

METHODS

This study is a retrospective review of patients undergoing esophagectomy in the National Surgical Quality Improvement Program (NSQIP) Targeted Esophagectomy database from 2016 to 2019. Patients were stratified by BMI < 35 versus BMI > 35, with the primary outcome being leak post-esophagectomy. Univariate analyses were performed for demographics and post-operative outcomes, and multivariate analyses were performed specifically for the primary outcome of anastomotic leak (all diagnoses and malignancy/dysplasia subgroup). This study was approved by the Institutional Review Board.

RESULTS

Of 4165 patients, 439 (10.5%) had a BMI > 35. Patients with BMI > 35 were often younger (mean age 60 vs 64 years, p < 0.001), White (p < 0.001), female (p < 0.001), non-smoker (p < 0.001), diabetic (p < 0.001), with hypertension (p < 0.001), and ASA ≥ 3 (p < 0.001). There were no differences between BMI groups with regard to indication for esophagectomy (malignancy/dysphasia vs other), conversion to open, mortality, or length of stay. The BMI > 35 cohort reported higher operative times (p < 0.001), open operative approach (p = 0.04), superficial surgical site infection (p < 0.001), return to operating room (p = 0.01), and leak (13.5% vs 10.1%, p = 0.01). BMI > 35 was not an independent predictor of leak for all diagnoses; however, the subgroup analysis of esophagectomy for malignancy/dysplasia demonstrated that BMI > 35 was predictive of leak (OR 1.42, 95% CI 1.05-1.91), as well as operative time and hypertension.

CONCLUSION

Patients with a BMI > 35 and who undergo esophagectomy have a higher rate of anastomotic leak. BMI > 35 was also an independent predictor of leak when esophagectomy was performed for malignancy/dysplasia, but not for all diagnoses. The risk of anastomotic leak should be considered in morbidly obese patients undergoing esophagectomy, particularly for malignancy.

Surface microdialysis measures local tissue metabolism after Ivor Lewis esophagectomy; an attempt to predict anastomotic defect

Anastomotic defect (AD) after esophagectomy can lead to severe complications with need for surgical or endoscopic intervention. Early detection enables early treatment and can limit the consequences of the AD. As of today, there are limited methods to predict AD. In this study, we have used microdialysis (MD) to measure local metabolism at the intrathoracic anastomosis. Feasibility and possible diagnostic use were investigated. Sixty patients planned for Ivor Lewis esophagectomy were enrolled. After construction of the anastomosis, surface MD (S-MD) probes were attached to the outer surface of the esophageal remnant and the gastric conduit in close vicinity of the anastomosis and left in place for 7 postoperative days (PODs). Continuous sampling of local tissue concentrations of metabolic substances (glucose, lactate, and pyruvate) was performed postoperatively. Outcome, defined as AD or not according to Esophagectomy Complications Consensus Group definitions, was recorded at discharge or at first postoperative follow up. Difference in concentrations of metabolic substances was analyzed retrospectively between the two groups by means of artificial neural network technique. S-MD probes can be attached and removed from the gastric tube reconstruction without any adverse events. Deviating metabolite concentrations on POD 1 were associated with later development of AD. In subjects who developed AD, no difference in metabolic concentrations between the esophageal and the gastric probe was recorded. The technical failure rate of the MD probes/procedure was high. S-MD can be used in a clinical setting after Ivor Lewis esophagectomy. Deviation in local tissue metabolism on POD 1 seems to be associated with development of AD. Further development of MD probes and procedure is required to reduce technical failure.

Understanding the supportive care needs among discharged patients with esophageal cancer after esophagectomy: A qualitative study

PURPOSE

Patients with esophageal cancer experience physical and psychosocial difficulties after surgery. Understanding their unmet supportive care needs could help medical staff in providing high quality of care. This study aimed to gain insights into the supportive care needs of discharged patients with esophageal cancer after esophagectomy.

METHOD

A descriptive qualitative study design was used. A purposive sample of 20 patients was studied using semi-structured interviews. The thematic analysis approach was used to analyze the data.

RESULTS

Four themes and 14 sub-themes emerged from the analysis: (1) symptom management needs (dysphagia, reflux, fatigue, and other symptoms), (2) dietary and nutritional needs (unclear nutrition information, eating habit change, and dining out restriction), (3) psychosocial adjustment needs (stigma, dependency, fear of recurrence, and desire for normalcy), and (4) social support needs (medical staff support, family support, and peer support).

CONCLUSION

Chinese patients with esophageal cancer have various unmet supportive care needs after esophagectomy. Medical professionals should recognize patients' unmet supportive care needs in time, provide professional access and practical guidance, relieve their bad mood, and fully utilize online communicating channels, such as a consulting platform or a WeChat group, for further support.

Impact of postoperative NSAIDs administration on anastomotic leak after esophago-gastric surgery: systematic review and meta-analysis

Anastomotic leak (AL) is a feared complication of esophago-gastric surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat postoperative pain. Previous analyses conveyed heterogeneous data for colorectal surgery with a tendency toward high risk for AL after NSAIDs administration. In the setting of upper gastrointestinal (GI) surgery data are even more puzzled. The purpose of the present study was to assess whether an association exists between postoperative NSAIDs administration and AL after esophago-gastric surgery. PubMed, MEDLINE, Scopus, and Web of Science were searched up to November 2022. The included studies evaluated outcomes for NSAIDs vs. no NSAIDs administration after esophago-gastric surgery. The primary outcome was anastomotic leak (AL). Risk ratio (RR) and 95% confidence intervals (95% CI) were used to assess pooled effect size and relative inference. Six studies (43,784 patients) were included. The patient age ranged from 31 to 84 years, 82.4% were males and preoperative BMI ranged from 15 to 31 kg/m². Esophagectomy was performed in 95% of patients. NSAIDs were administered in 18,075 (41.3%) patients. The cumulative incidence of AL was similar for NSAIDs vs. no NSAIDs (13.6% vs. 13.4%). The risk for postoperative AL was similar for NSAIDs vs. no NSAIDs administration (RR 1.49; 95% CI 0.81-2.75; p = 0.19). The cumulative incidence of postoperative gastrointestinal bleeding (0.36% vs. 0.39%), acute kidney injury (0.62% vs. 0.71%), and in-hospital mortality (2.39% vs. 2.66%) were comparable. NSAIDs administration for postoperative analgesia seems not associated with an increased risk for AL after esophago-gastric surgery.

Improving outcomes in patients with oesophageal cancer

The care of patients with oesophageal cancer or of individuals who have an elevated risk of oesophageal cancer has changed dramatically. The epidemiology of squamous cell and adenocarcinoma of the oesophagus has diverged over the past several decades, with a marked increase in incidence only for oesophageal adenocarcinoma. Only in the past decade, however, have molecular features that distinguish these two forms of the disease been identified. This advance has the potential to improve screening for oesophageal cancers through the development of novel minimally invasive diagnostic technologies predicated on cancer-specific genomic or epigenetic alterations. Surgical techniques have also evolved towards less invasive approaches associated with less morbidity, without compromising oncological outcomes. With improvements in multidisciplinary care, advances in radiotherapy and new tools to detect minimal residual disease, certain patients may no longer even require surgical tumour resection. However, perhaps the most anticipated advance in the treatment of patients with oesophageal cancer is the advent of immune-checkpoint inhibitors, which harness and enhance the host immune response against cancer. In this Review, we discuss all these advances in the management of oesophageal cancer, representing only the beginning of a transformation in our quest to improve patient outcomes.

Weight loss during neoadjuvant therapy and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

Neoadjuvant therapy (NAT) has become common worldwide for resectable advanced esophageal cancer and frequently involves weight loss. Although failure to rescue (death after major complications) is known as an emerging surgical quality measure, little is known about the impact of weight loss during NAT on failure to rescue. This retrospective study aimed to investigate the association of weight loss during NAT and short-term outcomes, including failure to rescue after esophagectomy.

MATERIALS AND METHODS

Patients who underwent esophagectomy after NAT between July 2010 and March 2019 were identified from a Japanese nationwide inpatient database. Based on quartiles of percent weight change during NAT, patients were grouped into four categories of gain, stable, small loss, and loss (>4.5%). The primary outcomes were failure to rescue and in-hospital mortality. The secondary outcomes were major complications, respiratory complications, anastomotic leakage, and total hospitalization costs. Multivariable regression analyses were used to compare outcomes between the groups, adjusting for potential confounders, including baseline BMI.

RESULTS

Among 15 159 eligible patients, in-hospital mortality and failure to rescue occurred in 302 (2.0%) and 302/5698 (5.3%) patients, respectively. Weight loss (>4.5%) compared to gain was associated with increased failure to rescue and in-hospital mortality [odds ratios 1.55 (95% CI: 1.10-2.20) and 1.53 (1.10-2.12), respectively]. Weight loss was also associated with increased total hospitalizations costs, but not with major complications, respiratory complications, and anastomotic leakage. In subgroup analyses, regardless of baseline BMI, weight loss (>4.8% in nonunderweight or >3.1% in underweight) was a risk factor for failure to rescue and in-hospital mortality.

CONCLUSION

Weight loss during NAT was associated with failure to rescue and in-hospital mortality after esophagectomy, independent of baseline BMI. This emphasizes the importance of weight loss measurement during NAT to assess the risk for a subsequent esophagectomy.

Robotic versus open Ivor–Lewis esophagectomy: A more accurate lymph node dissection without burdening the leak rate

BACKGROUND

Robotic-assisted minimally invasive esophagectomy (RAMIE) combines the beneficial effects of minimally invasive surgery on postoperative complications, especially on pulmonary ones, with the safety of the anastomosis performed in open surgery. Moreover, RAMIE could allow a more accurate lymphadenectomy.

METHODS

We reviewed our database to identify all patients with adenocarcinoma of the esophagus treated by Ivor-Lewis esophagectomy in the period January 2014 to June 2022. Patients were divided according to the thoracic approach into RAMIE and open esophagectomy (OE) groups. We compared the groups for early surgical outcomes, 90-day mortality as well as R0 rate, and the number of lymph nodes harvested.

RESULTS

We identified 47 patients in RAMIE and 159 patients in the OE group. Baseline characteristics were comparable. Operative time was significantly longer for RAMIE procedures (p < 0.01); however, we did not observe the difference in overall (RAMIE 55.5% vs. OE 61%, p = 0.76) and severe complications rate (RAMIE 17% vs. OE 22.6%, p = 0.4). The anastomotic leak rate was 2.1% after RAMIE and 6.9% after OE (p = 0.56). We did not report the difference in 90-day mortality (RAMIE 2.1% vs. OE 1.9%, p = 0.65). In the RAMIE group, we observed a significantly higher number of thoracic lymph nodes harvested, with a median of 10 lymph nodes in the RAMIE group versus 8 in the OE group (p < 0.01).

CONCLUSIONS

In our experience, RAMIE has morbimortality rates comparable to OE. Moreover, it allows a more accurate thoracic lymphadenectomy which results in a higher thoracic lymph nodes retrieval rate.

A Population-Based Study Using Belgian Cancer Registry Data Supports Centralization of Esophageal Cancer Surgery in Belgium

BACKGROUND

Esophageal cancer surgery outcomes benefit from higher hospital volumes. Despite the evidence, organization of national health care often is complex and depends on various factors. The volume-outcome results of this population-based study supported national health policy measures regarding concentration of esophageal resections in Belgium.

METHODS

The Belgian Cancer Registry (BCR) database was linked to administrative data on cancer treatment. All Belgian patients with newly diagnosed esophageal cancer in 2008-2018 undergoing resection were allocated to the hospital at which surgery was performed. The study assessed hospital volume association with 90-day mortality and 5-year overall survival, classifying average annual hospital volume of resections as low (LV, <6), medium (MV, 6-19), or high (HV, ≥20) and as a continuous covariate in the regression models.

RESULTS

The study included 4156 patients who had surgery in 79 hospitals (2 HV hospitals [37% of all surgeries], 12 MV hospitals [30% of all surgeries], and 65 LV hospitals [33% of all surgeries]). Adjusted 90-day mortality in HV hospitals was lower than in LV hospitals (odds ratio [OR], 0.37; 95% CI, 0.21-0.65; p = 0.001). Case-mix adjusted 5-year survival was superior in HV versus LV (hazard ratio [HR], 0.43; 95% CI, 0.31-0.60; p < 0.001). The continuous model demonstrated a lower 90-day mortality (OR, 0.40; 95% CI, 0.23-0.71; p = 0.002) and a superior 5-year survival (HR, 0.45; 95% CI, 0.33-0.63; p < 0.001) in hospitals with volumes of 40 or more resections annually.

CONCLUSION

Population-based data from the BCR confirmed a strong volume-outcome association for esophageal resections. Improved 5-year survival in centers with annual volumes of 20 or more resections was driven mainly by the achievement of superior 90-day mortality. These findings supported centralization of esophageal resections in Belgium.

What has the past taught us about the future in esophageal cancer? Personal reflections

Since the first successful esophagectomy for cancer in 1913 spectacular advancements have been made in diagnosis, staging, and therapy. Refinement of imaging, surgery, perioperative management together with multidisciplinary collaboration are the cornerstones. Today therapy with curative option is offered to more patients than ever. Further innovations in imaging, molecular biology, genetics, artificial intelligence, machine learning, robotics, nanotechnology will have an increasing impact. The end result being a unique therapeutic plan shaped on each patient's individual profile.

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Optimal discharge planning for esophagectomy patients with enhanced recovery after surgery: Recommendations

Background

Studies have suggested that the postoperative length of stay (PLOS) of esophagectomy patients under the enhanced recovery after surgery (ERAS) pathway should be >10 days as against the previously recommended 7 days. We investigated the distribution and influencing factors of PLOS in the ERAS pathway in order to recommend an optimal planned discharge time.

Methods

This was a single-center retrospective study of 449 patients with thoracic esophageal carcinoma who underwent esophagectomy and perioperative ERAS between January 2013 and April 2021. We established a database to prospectively document the causes of delayed discharge.

Results

The mean and median PLOS were 10.2 days and 8.0 days (range: 5-97), respectively. Patients were divided into four groups: group A (PLOS ≤ 7 days), 179 patients (39.9%); group B (8 ≤ PLOS ≤ 10 days), 152 (33.9%); group C (11 ≤ PLOS ≤ 14 days), 68 (15.1%); group D (PLOS > 14 days), 50 patients (11.1%). The main cause of prolonged PLOS in group B was minor complications (prolonged chest drainage, pulmonary infection, recurrent laryngeal nerve injury). Severely prolonged PLOS in groups C and D were due to major complications and comorbidities. On multivariable logistic regression analysis, open surgery, surgical duration >240 min, age >64 years, surgical complication grade >2, and critical comorbidities were identified as risk factors for delayed discharge.

Conclusions

The optimal planned discharge time for patients undergoing esophagectomy with ERAS should be 7-10 days with a 4-day discharge observation window. Patients at risk of delayed discharge should be managed adopting PLOS prediction.

Development of nomograms predictive of anastomotic leakage in patients before minimally invasive McKeown esophagectomy

Purpose

The present study aims to identify factors related to anastomotic leakage before esophagectomy and to construct a prediction model.

Methods

A retrospective analysis of 285 patients who underwent minimally invasive esophagectomy (MIE). An absolute shrinkage and selection operator was applied to screen the variables, and predictive models were developed using binary logistic regression.

Results

A total of 28 variables were collected in this study. LASSO regression analysis, combined with previous literature and clinical experience, finally screened out four variables, including aortic calcification, heart disease, BMI, and FEV1. A binary logistic regression was conducted on the four predictors, and a prediction model was established. The prediction model showed good discrimination and calibration, with a C-statistic of 0.67 (95% CI, 0.593-0.743), a calibration curve fitting a 45° slope, and a Brier score of 0.179. The DCA demonstrated that the prediction nomogram was clinically useful. In the internal validation, the C-statistic still reaches 0.66, and the calibration curve has a good effect.

Conclusions

When patients have aortic calcification, heart disease, obesity, and a low FEV1, the risk of anastomotic leakage is higher, and relevant surgical techniques can be used to prevent it. Therefore, the clinical prediction model is a practical tool to guide surgeons in the primary prevention of anastomotic leakage.

ESDE-MIE fellowship: a descriptive analysis of the first experiences

Esophageal resection is a high-risk and technically demanding procedure, with a long proficiency-gain curve. The European Society Diseases of the Esophagus (ESDE)-Minimally Invasive Esophagectomy (MIE) training program was launched in 2018 for European surgeons willing to train and to begin a career undertaking MIE. The aim of this study was to evaluate the first experience of the ESDE-MIE fellowship and relate this to the initially predetermined core principles and objectives of the program. Between October 2021 and May 2022, the participating fellows, in collaboration with the ESDE Educational Committee, initiated a survey to assess the outcome and experience of these fellowships. Data from each individual fellowship were analysed and reported in a descriptive manner. Between 2018 and 2022, in total, five fellows have completed the ESDE-MIE fellowship program. Despite the COVID-19 outbreak just the year after its launch, predetermined clinical and research goals were achieved in all cases. Each of the fellows were able to assist in a median of 40 (IQR 27-69) MIE and/or Robot assisted (RA)MIE procedures, of a total median of 115 (IQR 83-123) attended Upper GI cases. After the fellowship, MIE has been fully adopted by the fellows who returned to their home institutions as Upper GI surgeons. The fellowship was concluded by the European Union of Medical Specialists (UEMS) Multidisciplinary Joint Committee (MJC) certification in Upper GI Surgery, which was successfully obtained by all who took part. Based on the experience of the first five fellows, the ESDE-MIE training fellowship meets with the expected needs even despite the COVID-19 outbreak in 2019. Furthermore, these fellows have returned home and integrated MIE into their independent surgical practice, affirming the ability of this program to train the next generation of MIE surgeons, even in the most challenging of circumstances.

Trends in surgical techniques for the treatment of esophageal and gastroesophageal junction cancer: the 2022 update

The aim of this study was to evaluate the current practice in surgical techniques for esophageal and gastroesophageal junction cancer surgery worldwide and to compare the results to the previous surveys in 2007 and 2014. An online survey was sent out among surgical members of the International Society for Diseases of the Esophagus, the World Organization for Specialized Studies on Disease of the Esophagus, the International Gastric Cancer Association, the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland and Dutch gastroesophageal surgeons via the network of the investigators. In total, 260 surgeons completed the survey representing 52 countries and 6 continents; Europe 56%, Oceania 14%, Asia 14%, South-America 9%, North-America 7%. Of the responding surgeons, 39% worked in a hospital that performed >51 esophagectomies per year. Total minimally invasive esophagectomy was the preferred technique (53%) followed by hybrid esophagectomy (26%) of which 7% consisted of a minimally invasive thoracic phase and 19% of a minimally invasive abdominal phase. Total open esophagectomy was preferred by 21% of the respondents. Total minimally invasive esophagectomy was significantly more often performed in high-volume centers compared with non-high-volume centers (P = 0.002). Robotic assistance was used in 13% during the thoracic phase and 6% during the abdominal phase. Minimally invasive transthoracic esophagectomy has become the preferred approach for esophagectomy. Although 21% of the surgeons prefer an open approach, 26% of the surgeons perform a hybrid procedure which may reflect further transition towards the use of total minimally invasive esophagectomy.

Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy

BACKGROUND

Previous studies have suggested that postoperative non-steroidal anti-inflammatory drug (NSAID) use may increase the risk of anastomotic leakage after colorectal surgery. However, the association between NSAIDs and anastomotic leakage after oesophagectomy is unclear. The aim of this retrospective study was to assess the effect of early postoperative NSAID use on anastomotic leakage after oesophagectomy.

METHODS

The Data of patients who underwent oesophagectomy for cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the association between NSAID use in the early postoperative period (defined as the day of and the day after surgery) and short-term outcomes, adjusting for potential confounders. The primary outcome was anastomotic leakage. The secondary outcomes were acute kidney injury, gastrointestinal bleeding, and mortality.

RESULTS

Among 39 418 eligible patients, early postoperative NSAIDs were used by 16 211 individuals (41 per cent). Anastomotic leakage occurred in 5729 patients (15 per cent). In stabilized IPTW analyses, NSAIDs were not associated with anastomotic leakage (odds ratio 1.04, 95 per cent c.i. 0.97 to 1.10). The proportions of acute kidney injury and gastrointestinal bleeding, as well as 30-day mortality and in-hospital mortality, did not differ according to NSAID use. Propensity score matching and instrumental variable analyses demonstrated similar results.

CONCLUSION

Early postoperative NSAID use was not associated with anastomotic leakage or other complications in patients who underwent oesophagectomy.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Open left thoracoabdominal esophagectomy a viable option in the era of minimally invasive esophagectomy

Minimally invasive surgical technique has become standard at many institutions in esophageal cancer surgery. In some situations, however other surgical approaches are required. Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky distal esophageal tumors, but there are concerns that this approach is associated with significant morbidity. Prospectively entered esophagectomy databases from three high-volume centers were reviewed for patients undergoing LTE or MIE 2009-2019. Patient demographics, tumor characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 915 patients were included in the study, LTE was applied in 684 (74.8%) patients, and MIE in 231 (25.2%) patients. LTE patients had more locally advanced tumor stage and received more neoadjuvant treatment. Patients treated with MIE had more comorbidities. The results showed no difference in overall postoperative complications (LTE = 61.7%, MIE = 65.7%, P = 0.289), severe complications (Clavien-Dindo ≥IIIa (LTE = 25.9%, MIE 26.8%, P = 0.806)), pneumonia (LTE = 29.0%, MIE = 24.7%, P = 0.211), anastomotic leak (LTE = 7.8%, MIE = 11.3%, P = 0.101), or in-hospital mortality (LTE = 2.6%, MIE = 3.5%, P = 0.511). Median number of resected lymph nodes was 24 for LTE and 25 for MIE (P = 0.491). LTE was used for more advanced tumors in patients that were more likely to have received neoadjuvant treatment compared with MIE, however postoperative morbidity, mortality, and oncologic outcomes were equivalent to that of MIE in this cohort. In conclusion open resection with left thoracoabdominal approach is a valid option in selected patients when performed at high-volume esophagectomy centers.

Predicting mortality in patients with anastomotic leak after esophagectomy: development of a prediction model using data from the TENTACLE-Esophagus study

Anastomotic leak (AL) is a common but severe complication after esophagectomy, and over 10% of patients with AL suffer mortality. Different prognostic factors in patients with AL are known, but a tool to predict mortality after AL is lacking. This study aimed to develop a prediction model for postoperative mortality in patients with AL after esophagectomy. TENTACLE-Esophagus is an international retrospective cohort study, which included 1509 patients with AL after esophagectomy. The primary outcome was 90-day postoperative mortality. Previously identified prognostic factors for mortality were selected as predictors: patient-related (e.g. comorbidity, performance status) and leak-related predictors (e.g. leucocyte count, overall gastric conduit condition). The prediction model was developed using multivariable logistic regression and validated internally using bootstrapping. Among the 1509 patients with AL, 90-day mortality was 11.7%. Sixteen predictors were included in the prediction model. The model showed good performance after internal validation: the c-index was 0.79 (95% confidence interval 0.75-0.83). Predictions for mortality by the internally validated model aligned well with observed 90-day mortality rates. The prediction model was incorporated in an online tool for individual use and can be found at: https://www.tentaclestudy.com/prediction-model. The developed prediction model combines patient-related and leak-related factors to accurately predict postoperative mortality in patients with AL after esophagectomy. The model is useful for clinicians during counselling of patients and their families and may aid identification of high-risk patients at diagnosis of AL. In the future, the tool may guide clinical decision-making; however, external validation of the tool is warranted.

Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan

BACKGROUND

Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear.

OBJECTIVE

The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer.

METHODS

Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders.

RESULTS

Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results.

CONCLUSIONS

EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.

The Implementation of Minimally Invasive Surgery in the Treatment of Esophageal Cancer: A Step Toward Better Outcomes?

Esophagectomy is considered the cornerstone of the radical treatment of esophageal cancer. In the past decades, minimally invasive techniques including robot-assisted approaches have become popular. The aim of minimally invasive surgery is to reduce the surgical trauma, resulting in faster recovery, reduction in complications, and better quality of life after surgery. Secondly, a more precise dissection may lead to better oncological outcomes. As such, minimally invasive esophagectomy is now seen by many as the standard surgical approach. However, evidence supporting this viewpoint is limited. This narrative review summarizes recent prospectively designed studies on minimally invasive esophagectomy.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

The safety of esophageal cancer surgery during COVID-19

BACKGROUND

The ongoing coronavirus disease 2019 (COVID-19) pandemic has drastically challenged the safety of on esophageal cancer (EC) surgery during COVID-19. The study aimed to evaluate the safety of EC surgery during the COVID-19 pandemic.

METHODS

This systematic review was performed in accordance with the PRISMA-P 2015 guidelines and registered in PROSPERO (registration number: CRD42022335164). A systematic search of PubMed, Embase, Cochrane Library, Web of Science, Medline, Chinese National Knowledge Infrastructure database, Chinese Scientific Journal database, and Wan Fang database was conducted to identify potentially relevant publications from January 2020 to May 2022. All data were independently extracted by two researchers. We will apply a fixed-effect model or random effect model basis on the heterogeneity test and employ with RevMan 5.4.1 software for data synthesis. The dichotomous surgical outcomes used risk ratios or risk differences, and for continuous surgical outcomes, mean differences (MD) or standardized MD, both with 95% confidence intervals were used. The primary outcomes were postoperative complications, anastomotic leaks, and mortality. The secondary outcomes were total hospital stay, postoperative stay, preoperative waiting, operation time, blood loss, transfusion, postoperative intensive care unit (ICU) stay, number of patients needing ICU stay, and 30-day readmission.

RESULTS

This study will comprehensively summarize the high-quality trials to determine the safety of EC surgery during COVID-19.

CONCLUSION

Our systematic review and meta-analysis will present evidence for the safety of EC surgery during COVID-19.

[Surgical Treatment of Esophageal Cancer-New Technologies, Modern Concepts]

Das Ösophaguskarzinom wird in Deutschland meist in spezialisierten Zentren entsprechend den Leitlinien multimodal und interdisziplinär therapiert. In den kommenden Jahren wird die Zentralisierung der Ösophaguschirurgie in Deutschland durch die Festlegung neuer Mindestmengen weiter voranschreiten. Dieser Artikel soll neue Technologien für die chirurgische Therapie des Ösophaguskarzinoms und zudem aktuelle onkologische Konzepte aus der Sicht eines High-volume-Centers vorstellen.

Robot-assisted transthoracic hybrid esophagectomy versus open and laparoscopic hybrid esophagectomy: propensity score matched analysis of short-term outcome

PURPOSE

Minimally invasive en-bloc esophagectomy is associated with a reduction of postoperative morbidity. This was demonstrated for both total minimally invasive and hybrid esophagectomy. However, little is known about any benefits of robotic assistance compared to the conventional minimally invasive technique, especially in hybrid procedures.

METHODS

For this retrospective study, all consecutive patients who had undergone elective esophagectomy with circular stapled intrathoracic anastomosis using the open and the minimally invasive hybrid technique at the University Hospital Magdeburg, from January 2010 to March 2021 were considered for analysis.

RESULTS

In total, 137 patients (60.4%) had undergone open esophagectomy. In 45 patients (19.8%), the laparoscopic hybrid technique and in 45 patients (19.8%), the robot-assisted hybrid technique were applied. In propensity score matching analysis comparing the open with the robotic hybrid technique, significant differences were found in favor of the robotic technique (postoperative morbidity, p < 0.01; hospital length of stay, p < 0.01; number of lymph nodes retrieved, p = 0.048). In propensity score matching analysis comparing the laparoscopic with the robotic hybrid technique, a significant reduction of the rate of postoperative delayed gastric emptying (p = 0.02) was found for patients who had undergone robotic esophagectomy. However, the operation time was significantly longer (p < 0.01).

CONCLUSIONS

En-bloc esophagectomy using the robotic hybrid technique is associated with a significant reduction of postoperative morbidity and of the hospital length of stay when compared to the open approach. However, when compared to the laparoscopic hybrid technique, only few advantages could be demonstrated.

Feasibility study of adjuvant chemotherapy with S-1 after curative esophagectomy following neoadjuvant chemotherapy for esophageal cancer

BACKGROUND

Despite advances in surgical techniques, long-term survival after esophagectomy for esophageal cancer remains unacceptably low, and more effective perioperative chemotherapy is expected. However, an important concern regarding the application of postoperative adjuvant chemotherapy is treatment toxicity. We aimed to evaluate the feasibility of adjuvant chemotherapy with S-1 in patients after esophagectomy.

METHODS

We investigated the tolerability of a 2-week administration followed by 1-week rest regimen of S1 as postoperative adjuvant therapy in 20 patients with esophageal squamous cell carcinoma who received neoadjuvant chemotherapy (NAC) and 22 patients who did not receive NAC during 2011-2020.

RESULTS

In the non-NAC group, the mean and median relative dose intensity (RDI) were 78.7% and 99.4%, respectively, and 11 patients (50%) had altered treatment schedules. The corresponding rates in the NAC group were 77.9% and 100%, respectively, and nine patients (45%) had altered treatment schedules, with no significant difference among the groups. Moreover, 17 patients (77.2%) in the non-NAC group and 16 patients (80.0%) in the NAC group continued S-1 treatment as planned for one year postoperatively, with no significant difference in the S-1 continuation rate (p = 0.500). Seventeen of 22 patients (77.3%) and 15 of 20 patients (75.0%) experienced several adverse events in the non-NAC and NAC groups, respectively. The frequency, severity, and type of adverse events were consistent among patients with and without NAC.

CONCLUSIONS

S-1 could be safely and continuously administered as adjuvant chemotherapy for patients with esophageal cancer regardless of NAC. Long-term prognosis should be evaluated for S-1 to become the standard treatment after esophagectomy.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

BACKGROUND

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

METHODS

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

RESULTS

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

CONCLUSION

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Acute gastric conduit dilation after minimally invasive esophagectomy: a 10-year experience

Despite decreasing overall morbidity with minimally invasive esophagectomy (MIE), conduit functional outcomes related to delayed emptying remain challenging, especially in the immediate postoperative setting. Yet, this problem has not been described well in the literature. Utilizing a single institutional prospective database, 254 patients who underwent MIEs between 2012 and 2020 were identified. Gastric conduit dilation was defined as a conduit occupying >40% of the hemithorax on the postoperative chest X-ray. Sixty-seven patients (26.4%) demonstrated acute conduit dilation. There was a higher incidence of conduit dilation in the patients who underwent Ivor Lewis esophagectomy compared to those with a neck anastomosis (67.2% vs. 47.1%; P = 0.03). Patients with dilated conduits required more esophagogastroduodenoscopies (EGD) (P < 0.001), conduit-related reoperations within 180 days (P < 0.001), and 90-day readmissions (P = 0.01). Furthermore, in 37 patients (25.5%) undergoing Ivor Lewis esophagectomy, we returned to the abdomen after intrathoracic anastomosis to reduce redundant conduit and pexy the conduit to the crura. While conduit dilation rates were similar, those who had intraabdominal gastropexy required EGD significantly less and trended toward a lower incidence of conduit-related reoperations (5.6% vs. 2.7%). Multivariable analysis also demonstrated that conduit dilation was an independent predictor for delayed gastric conduit emptying symptoms, EGD within 90 days, conduit-related reoperation within 180 days, and 30-day as well as 90-day readmission. Patients undergoing MIE with acute gastric conduit dilation require more endoscopic interventions and reoperations.