Transhiatal esophagectomy in a high volume institution

Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series

Background

Oesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40).

Results

The mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146.

Conclusion

No high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.

The Comparison of the Advantages of Neoadjuvant Chemoradiotherapy versus Postoperative Chemoradiotherapy: Outcomes in Esophageal Cancer Patients

BACKGROUND AND OBJECTIVES

Esophageal cancer is the eighth most common type of cancer worldwide. For the treatment of which, surgical intervention alone or with neoadjuvant chemoradiotherapy or chemotherapy is recommended. In this study, we aimed to compare the benefits of neoadjuvant chemoradiotherapy versus postoperative chemoradiotherapy.

PATIENTS AND METHODS

We collected data regarding 325 patients admitted for esophageal cancer to Qaem Hospital, Mashhad, Iran, during 2006-2016. The participants were divided into two groups of neoadjuvant and postoperative adjuvant therapies. Chi-square, McNemar, Kaplan-Mayer, and multivariate regression tests were performed using SPSS.

RESULTS

Gender, age, stage of the disease, tumor grade and location, disease histopathology, and the recurrence showed no significant differences between the two groups (P ˃ 0.05), but there was a significant association between the two types of treatment in terms of postoperative complications (P = 0.03). We followed up 147 patients postoperatively and found no significant differences between the groups (P ˃ 0.05).

CONCLUSION

No conclusion can be drawn on whether there are any advantages in adjuvant chemoradiotherapy over neoadjuvant approaches. Further confirmatory trials, particularly randomized trials, are necessary before any recommendations can be made.

Racial Disparity in Utilization of High-Volume Hospitals for Surgical Treatment of Esophageal Cancer

BACKGROUND

Utilization of high-volume hospitals (HVH) for esophagectomy has been associated with improved perioperative outcomes and reduced mortality. We aimed to test the hypothesis that black-white racial disparities exist in HVH utilization and identify predictors of in-hospital surgical outcomes of esophageal cancer while adjusting for HVH utilization patterns.

METHODS

We queried the New York Statewide Planning and Research Cooperative System database (1995 to 2012) for esophageal cancer patients who underwent surgical resection exclusively. Only records for patients with self-reported white or black race and a valid New York State ZIP code were included (n = 2,895). Analysis was performed to identify factors associated with HVH hospital (≥20 esophagectomies/year) utilization and determine predictors of complications and in-hospital mortality.

RESULTS

Black patients (361 [12.5%]) were significantly different (p < 0.001) than their white counterparts in the proportion of women, Medicaid, income distribution, and privately insured individuals. Although 55% patients overall utilized an HVH, blacks were significantly less likely to utilize an HVH than whites (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.14 to 0.24), even though 74.5% resided within 8.9 miles of one. Operations performed at HVHs were associated with lower in-hospital mortality (OR, 0.48; 95% CI, 0.35 to 0.65); however, mortality remained higher for blacks (OR, 2.04; 95% CI, 1.65 to 3.30; propensity matched OR, 2.45; 95% CI, 1.5 to 4.03).

CONCLUSIONS

Black patients were less likely to undergo esophagectomy at an HVH and experienced higher mortality. Efforts should be made to understand factors influencing patients' decision process and improve referral practices to ensure optimal care is provided across all segments of the population, irrespective of race, insurance, or income status.

Transthoracic versus transhiatal esophagectomy - influence on patient survival

Aim

To evaluate the survival of patients after surgery of the esophagus/cardia using the transthoracic and transhiatal methods.

Material and methods

In the years 2007–2011, 102 patients were radically treated for cancer of the esophagus/cardia: 24 women and 78 men at the average age of 59.5. There were 38 transthoracic procedures and 64 transhiatal procedures. All patients had a conduit made from the stomach, led through lodges in the esophagus and combined with the stump of the esophagus in the neck following the Collard method. Two-pole lymphadenectomies were performed in all patients.

Results

Patients after transthoracic procedures had statistically more (p < 0.05) lymph nodes removed than patients after transhiatal procedures. The 5-year survival rates in transhiatal and transthoracic procedures did not statistically differ, being 8% and 0% respectively. The length of patient survival was influenced by metastases in the nearby lymph nodes (p < 0.0001) and the presence of adenocarcinoma.

Conclusions

Surgical access (transhiatal and transthoracic surgery) does not affect the 5-year survival rates. Transhiatal surgery allows a greater number of lymph nodes to be removed. The main factor influencing the 5-year survival rate is the presence of metastases in the nearby lymph nodes.

Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer

BACKGROUND

An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer.

METHODS

Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel).

RESULTS

Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients.

CONCLUSIONS

Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.

Impact of Positive Margins on Survival in Patients Undergoing Esophagogastrectomy for Esophageal Cancer

BACKGROUND

Multimodality treatment that includes esophagogastrectomy may represent the best option for curing accurately staged patients with esophageal cancer. We analyzed the impact of incomplete resection on outcomes after esophagogastrectomy for esophageal cancer.

METHODS

The incidence of positive margins for patients who underwent esophagogastrectomy without induction therapy for pathologic T1-3N0-1M0 esophageal cancer of the mid and lower esophagus from 2003 to 2006 in the National Cancer Database was analyzed with multivariate logistic regression. The impact of positive margins on survival was assessed using Kaplan-Meier and Cox proportional hazards analysis.

RESULTS

Positive margins occurred in 342 of 3,125 patients (10.9%) who met study criteria. Increasing clinical T status was an independent predictor of positive margins in multivariate analysis, but the chance of positive margins decreased with larger facility case volumes. The presence of clinical nodal disease was not predictive of an incomplete resection. The 5-year survival of patients with positive margins (13.8%, 95% confidence interval [CI]: 10.5% to 18.1%) was significantly worse than that for patients with negative margins (46.3%, 95% CI: 44.4% to 48.3%, p < 0.001). Both microscopic residual disease (hazard ratio 1.37, 95% CI: 1.16 to 1.60, p < 0.001) and gross residual disease (hazard ratio 1.98, 95% CI: 1.62 to 2.42, p < 0.001) predicted worse survival in multivariate analysis of the entire cohort. Receiving adjuvant chemoradiation therapy slightly improved 5-year survival of patients with positive margins (16.9%, 95% CI: 11.3% to 23.6%, versus 13.5%, 95% CI: 9% to 20.3%, p < 0.001).

CONCLUSIONS

Positive margins are associated with poor survival, and adjuvant therapy only marginally improved prognosis. Future studies are needed to better evaluate whether induction therapy can lower the incidence of positive margins.

Transhiatal Esophagectomy without Mediastinal Manipulation for Lower Third Esophageal and Cardial Cancers: The First Experience of a New Technique

BACKGROUND

Considering the poor survival rate of patients with esophageal cancers, mainly due to the disease effects and surgical co morbidities, we have aimed to introduce a new method of Transhiatal Esophagectomy (THE) without mediastinal manipulation for lower third esophageal and cardial cancers. It has suggested that using this technique would decrease mentioned complications.

METHODS

In this prospective study, patients with esophageal cancer who referred for surgical treatment have enrolled and undergone to new method of THE, without mediastinal manipulation. Pre and post-operative morbidities as well as the duration of procedure, duration of hospital and ICU stay have recorded. All patients have followed up or 4-40 months.

RESULTS

In this study 53 patients with mean age of 55.2+/-10.3 years have undergone esophagectomy, and then in 50 of them the new method has performed. Median operative time and volume of blood loss was 120 minutes and 130 ml, respectively. Median duration of hospital and ICU stay was 7 and 1 day, respectively. There were no Pre-operative mortalities, arrhythmia, hemodynamic instability and mediastinal vessels injury. The most common co morbidities have related to our new method were mediastinal pleura injury, anastomotic leaks and anastomotic narrowing with 20%, 16% and 10% reported rate, respectively.

CONCLUSION

The findings of current study have indicated that transhiatal esophagectomy without mediastinal manipulation, has represented a safe and effective method for treatment of lower third esophageal and cardial cancers due to its potential advantages of decreased blood loss, being a less traumatic procedure, minimal cardiopulmonary complications and low rate of hospital mortality.

Outcomes after transhiatal esophagectomies in an eastern-European low-volume center

BACKGROUND

The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV).

AIMS

Our analysis, which to the authors' knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania.

STUDY DESIGN

Retrospective observational study.

METHODS

In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%).

RESULTS

The majority of cancer-group patients had T3/N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively. Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2-36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months.

CONCLUSION

Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite being significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers.

Minimally invasive esophagectomy in the elderly

OBJECTIVE

A retrospective analysis of a prospectively maintained database to evaluate our experience in elderly patients (>70 years) undergoing Thoracolaparoscopic esophagectomy for cancer oesophagus. To ascertain whether age, is a limiting factor for patients undergoing minimally invasive esophagectomy.

METHODS

All Patients above 70 years of age, referred to the Gastro-esophageal clinic were included in the study. Tumours were staged as per AJCC 6th ed. 2002. Patients diagnosed with T1/2/3, N0/1 lesion of the mid/lower oesophagus (Infra Azygous) and type I and II Gastro esophageal junction tumours were included in the study. Patients with ASA grade IV were excluded. All patients who underwent Thoracolaparoscopic esophagectomy from January 2009 till January 2012 were evaluated for their perioperative outcomes.

RESULTS

Sixty eight patients underwent Minimal Invasive esophagectomy from January 2009 to January 2012. There were 45 males and 23 females. The average age in elderly group was 75.76 ± 5.96 years (range 70 to 91). Mean operative time was 178.84 ± 65.26 min, mean blood loss 143.84 ml(range 32-450 ml), mean ICU stay 3.84 days(range 2-11 days) and mean hospital stay was 12.76 days(range 8-21 days). Pneumonia and Cardiac related complications occurred in 10.30 % and 1.47 % patients respectively. None of the procedures required conversion to open thoracotomy.

CONCLUSIONS

Thoracolaparoscopic esophagectomy is feasible and surgically safe in elderly patients with low morbidity and mortality. Thus age of a patient should not be considered a limiting factor.

ULTRAMINI ABSTRACT

This is an original article about our experience of thoracolaparoscopic esophagectomy for cancer esophagus in elderly patients. After analyzing the data we feel that age of the patient cannot be a truly limiting factor for patient diagnosed of esophageal cancer to undergo minimally invasive esophagectomy.

Pre-therapy laparoscopic feeding jejunostomy is safe and effective in patients undergoing minimally invasive esophagectomy for cancer

OBJECTIVE

Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients.

DESIGN

This research is a retrospective case series.

SETTING

This study was conducted in a university tertiary care center.

PATIENTS

Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy.

MAIN OUTCOME MEASURES

The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients.

RESULTS

One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection.

CONCLUSION

A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

Reporting of short-term clinical outcomes after esophagectomy: a systematic review

OBJECTIVE

This review summarizes reporting of complications of esophageal cancer surgery.

BACKGROUND

Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects.

METHODS

Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken.

RESULTS

Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity.

CONCLUSIONS

Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a "core outcome set" is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.

Long-term outcomes of extended proximal gastrectomy for oesophagogastric junctional tumours

BACKGROUND

There is no consensus on the optimum approach for resection of oesophagogastric junctional (OGJ) tumours. We prospectively evaluated the efficacy of transabdominal radical extended proximal gastrectomy with oesophagogastric anastomosis (EPGOG) for selected tumours of the OGJ.

METHODS

Between 1998 and 2007, 66 selected consecutive patients with tumours of the OGJ underwent successful EPGOG. Selection was limited to tumours where the maximal proximal extent was 36 cm ab oral. Pre-, peri-, and postoperative outcomes together with long-term survival data for these patients were prospectively collected.

RESULTS

Median theatre time was 242 min (range = 120-480), with a median blood loss of 300 ml (range = 50-1720). Eighty-nine percent of patients were extubated in theatre; major complications occurred in 9 (14%) patients, with an overall in-hospital mortality rate of 8%. Thirty-five (53%) patients had nodal disease and the median lymph node yield was 13 (range = 4-36), with an R0 resection rate of 80%. In terms of long-term outcomes, the 2- and 5-year actuarial survival rates were 54 ± 6% and 41 ± 6%.

CONCLUSION

Extended radical proximal gastrectomy with oesophagogastric anastomosis for selected junctional tumours is a feasible technique which does not compromise oncological principles as evidenced by an excellent long-term survival rate.

Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre)

BACKGROUND

The purpose of this study was to review the efficacy and safety of feeding jejunostomy in terms of achieving the nutritional goals in patients undergoing esophagectomy for carcinoma of oesophagus and complications associated hence with.

METHODS

A total of 463 patients underwent esophagogastrectomy for carcinoma oesophagus during this period. All these patients underwent Witzel feeding jejunostomy for post-operative enteral nutrition. Enteral feeding was started after 24 h of surgery and increased gradually till target caloric and protein value was achieved. Nutritional goals achieved were reviewed. All complications related to jejunostomy were recorded.

RESULTS

The study comprised of 463 patients who underwent elective esophagogastrectomy. Mean age was 58 +/- 8.4 in male patients and 55 +/- 4.2 years in female patients. Patients spend a mean of 19 +/- 8.4 (range 10-49) days on jejunostomy feed. The targeted calorie requirement was achieved by post-operative day 3 in 408 (88.12%) patients. The catheter blockage was one of the main complications during the course of feeding. Seven patients required relaparotomy for catheter blockage.

CONCLUSION

Feeding jejunostomy is an effective, safe, economic and well tolerated method of providing nutrition to the patients of esophagogastrectomy. Feeding jejunostomy should be done in every patient undergoing esophagectomy at the time of laparotomy.

Extended esophagectomy in elderly patients with esophageal cancer: minor effect of age alone in determining the postoperative course and survival

BACKGROUND

Elderly patients who undergo esophagectomy for cancer often have a high prevalence of coexisting diseases, which may adversely affect their postoperative course. We determined the relationship of advanced age (i.e., > or =70 years) with outcome and evaluated age as a selection criterion for surgery.

METHODS

Between January 1991 and January 2007, we performed a curative-intent extended transthoracic esophagectomy in 234 patients with cancer of the esophagus. Patients were divided into two age groups: <70 years (group I; 170 patients) and > or =70 years (group II; 64 patients).

RESULTS

Both groups were comparable regarding comorbidity (American Society of Anesthesiologists classification), and tumor and surgical characteristics. The overall in-hospital mortality rate was 6.2% (group I, 5%, vs. group II, 11%, P = 0.09). Advanced age was not a prognostic factor for developing postoperative complications (odds ratio, 1.578; 95% confidence interval, 0.857-2.904; P = 0.143). The overall number of complications was equal with 58% in group I vs. 69% in group II (P = 0.142). Moreover, the occurrence of complications in elderly patients did not influence survival (P = 0.174). Recurrences developed more in patients <70 years (58% vs. 42%, P = 0.028). The overall 5-year survival was 35%, and, when included, postoperative mortality was 33% in both groups (P = 0.676).The presence of comorbidity was an independent prognostic factor for survival (P = 0.002).

CONCLUSIONS

Advanced age (> or =70 years) has minor influence on postoperative course, recurrent disease, and survival in patients who underwent an extended esophagectomy. Age alone is not a prognostic indicator for survival. We propose that a radical resection should not be withheld in elderly patients with limited frailty and comorbidity.

An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy

OBJECTIVE

As part of our ongoing quality improvement effort, we evaluated our conventional approach to post-oesophagectomy management by comparing it to an alternative postoperative management pathway.

METHODS

Medical records from 386 consecutive patients undergoing oesophagectomy with gastric conduit for oesophageal cancer or Barrett's oesophagus with high-grade dysplasia were analysed retrospectively (July 2004 to August 2008). The conventional pathway involved a routine radiographic contrast swallow study at 5-7 days after oesophagectomy with initiation of oral intake if no leak was detected. In the alternative pathway, a feeding jejunostomy was placed for enteral feeding and used exclusively until oral intake was gradually initiated at home at 4 weeks after oesophagectomy. No contrast swallow was obtained in the alternative pathway group unless indicated by clinical suspicion of an anastomotic leak. Each group was analysed on an intention-to-treat basis with respect to anastomotic leak rates, length of hospitalisation, re-admission and other complications.

RESULTS

A total of 276 (72%) patients underwent conventional postoperative management, 110 (28%) followed the alternative pathway. Patient characteristics were similar in both the groups. The anastomotic leak rate was lower in the alternative pathway with three clinically significant leaks (2.7%) versus 33 in the conventional pathway (12.0%; p=0.01). Among patients undergoing a radiographic contrast swallow examination, a false-negative rate of 5.8% was observed. The swallow study of 14 patients (5.9%) was complicated by aspiration of oral contrast. Postoperatively, 7.3% of patients suffered from pneumonia. There were no significant differences overall in postoperative pulmonary or cardiac complications associated with either pathway. Median length of hospitalisation was 2 days shorter for the alternative pathway (7 days) than the conventional pathway (9 days; p<0.001). There was no significant difference in unplanned re-admission rates.

CONCLUSION

An alternative postoperative pathway following oesophagectomy involving delayed oral intake and avoidance of a routine contrast swallow study is associated with a shortened length of hospitalisation without a higher risk of complication after hospital discharge.

Benefits versus risks: a prospective audit. Feeding jejunostomy during esophagectomy

BACKGROUND

The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy.

METHODS

The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal.

RESULTS

Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 +/- 22.00 days (range 0-46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 +/- 16.24 vs. 14.69 +/- 19.04 days; p = 0.000) and postoperative complications (26.67 +/- 25.56 vs. 14.52 +/- 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy.

CONCLUSIONS

Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.

Outcome of low-volume surgery for esophageal cancer in a high-volume referral center

BACKGROUND

There is a known inverse relationship between the number of esophagectomies and in-hospital mortality. Our institute is a tertiary referral center with a high caseload of esophageal cancer patients, but with a low annual volume of esophagectomies. The objective of our study was to evaluate the results of esophageal cancer surgery in our institute and to compare these results with published data from high-surgical-volume institutions.

METHODS

Between 1995 and 2007, 1,499 patients with esophageal cancer were referred: for a second opinion only (n = 568), following earlier treatment (n = 103), for palliative treatment (n = 665) or for potentially curative treatment (local endoscopic therapy n = 5, definitive chemoradiotherapy n = 71, or surgery n = 87). The surgically treated patients were studied in detail, and compared with patients treated in high-surgical-volume hospitals.

RESULTS

Surgery consisted of a transhiatal (n = 71) or transthoracic (n = 12) esophagectomy, or exploration only (n = 4). Fifty-six (64%) patients received neoadjuvant treatment. A microscopic radical resection was achieved in 96%. Pathologic complete response rate was 25%. Forty-four (53%) patients had a complicated postoperative course, and one (1%) patient died. At a median postoperative follow-up of 30 (1-149) months, 1- and 3-year overall survival rates were 89% and 60%, respectively. No major differences were observed between our results and those presented in six large study cohorts with high operative volumes.

CONCLUSIONS

Outcome of low-volume esophageal surgery can be comparable to published high-surgical-volume results. More relevant factors other than hospital volume alone should be taken into account to improve outcome of esophageal cancer surgery.