In-hospital mortality after a surgical resection for esophageal cancer: analyses of the associated factors and historical changes

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Minimally invasive Ivor Lewis esophagectomy in the elderly patient: a multicenter retrospective matched-cohort study

Introduction

Several studies reported the advantages of minimally invasive esophagectomy over the conventional open approach, particularly in terms of postoperative morbidity and mortality. The literature regarding the elderly population is however scarce and it is still not clear whether elderly patients may benefit from a minimally invasive approach as the general population. We sought to evaluate whether thoracoscopic/ laparoscopic (MIE) or fully robotic (RAMIE) Ivor-Lewis esophagectomy significantly reduces postoperative morbidity in the elderly population.

Methods

We analyzed data of patients who underwent open esophagectomy or MIE/RAMIE at Mainz University Hospital and at Padova University Hospital between 2016 and 2021. Elderly patients were defined as those ≥ 75 years old. Clinical characteristics and the postoperative outcomes were compared between elderly patients who underwent open esophagectomy or MIE/RAMIE. A 1-to-1 matched comparison was also performed. Patients < 75 years old were evaluated as a control group.

Results

Among elderly patients MIE/RAMIE were associated with a lower overall morbidity (39.7% vs. 62.7%, p=0.005), less pulmonary complications (32.8 vs. 56.9%, p=0.003) and a shorter hospital stay (13 vs. 18 days, p=0.03). Comparable findings were obtained after matching. Similarly, among < 75 years-old patients, a reduced morbidity (31.2% vs. 43.5%, p=0.01) and less pulmonary complications (22% vs. 36%, p=0.001) were detected in the minimally invasive group.

Discussion

Minimally invasive esophagectomy improves the postoperative course of elderly patients reducing the overall incidence of postoperative complications, particularly of pulmonary complications.

Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis

BACKGROUND

Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy.

METHODS

PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality.

RESULTS

There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I² = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I² = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I² = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I² = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I² = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I² = 0%) between the pyloric drainage and no intervention groups.

CONCLUSIONS

Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.

The Application of Two-Stage Operation for High-Risk Patients with Oesophageal Cancer Following Gastrectomy

BACKGROUND

Oesophageal replacement by colonic interposition remains a major challenge due to its complexity and high incidence of complications; here we applied the two-stage operation strategy to oesophageal replacement by colonic interposition in high-risk oesophageal cancer patients following gastrectomy.

METHODS

We performed a retrospective analysis on the data of patients with a history of distal gastrectomy who underwent one-stage and two-stage oesophageal replacement by colonic interposition from February 2012 to February 2020, and explored the relationship between the staging strategy and postoperative outcomes.

RESULTS

The clinical data of 93 patients were collected and analysed. There were no significant differences in the patients' characteristics between the two groups (all p > 0.05), except for comorbidities and Charlson Comorbidity Index (all p < 0.05). The Clavien-Dindo score between the two groups was also not significantly different (p > 0.05). The logistic regression models revealed that patients who had received preoperative therapy had a higher Clavien-Dindo score (p < 0.05), but the stage strategy did not (p > 0.05).

CONCLUSIONS

The two-stage operation is feasible in high-risk patients who need to undergo colonic interposition for oesophageal replacement. At the same time, it lowers the technical threshold of colonic interposition for oesophageal replacement, increasing this surgical technique's acceptability.

Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery

BACKGROUND

Previous meta-analyses, with many limitations, have described the beneficial nature of minimal invasive procedures.

AIM

To compare all modalities of esophagectomies to each other from the results of randomized controlled trials (RCTs) in a network meta-analysis (NMA).

METHODS

We conducted a systematic search of the MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and CENTRAL databases to identify RCTs according to the following population, intervention, control, outcome (commonly known as PICO): P: Patients with resectable esophageal cancer; I/C: Transthoracic, transhiatal, minimally invasive (thoracolaparoscopic), hybrid, and robot-assisted esophagectomy; O: Survival, total adverse events, adverse events in subgroups, length of hospital stay, and blood loss. We used the Bayesian approach and the random effects model. We presented the geometry of the network, results with probabilistic statements, estimated intervention effects and their 95% confidence interval (CI), and the surface under the cumulative ranking curve to rank the interventions.

RESULTS

We included 11 studies in our analysis. We found a significant difference in postoperative pulmonary infection, which favored the minimally invasive intervention compared to transthoracic surgery (risk ratio 0.49; 95%CI: 0.23 to 0.99). The operation time was significantly shorter for the transhiatal approach compared to transthoracic surgery (mean difference -85 min; 95%CI: -150 to -29), hybrid intervention (mean difference -98 min; 95%CI: -190 to -9.4), minimally invasive technique (mean difference -130 min; 95%CI: -210 to -50), and robot-assisted esophagectomy (mean difference -150 min; 95%CI: -240 to -53). Other comparisons did not yield significant differences.

CONCLUSION

Based on our results, the implication of minimally invasive esophagectomy should be favored.

Risk factors and outcomes of fatal respiratory events after esophageal cancer surgery from 2011 through 2018: a nationwide cohort study in South Korea

BACKGROUND

Pulmonary complications are common after esophageal cancer surgery, but information regarding fatal respiratory events, such as postoperative acute respiratory distress syndrome (ARDS) and respiratory failure, is lacking. We aimed to investigate the prevalence, risk factors, and outcomes of fatal respiratory events after esophageal cancer surgery.

METHODS

We performed a retrospective population-based cohort study based on data from the National Health Insurance Service database in South Korea. All adult patients diagnosed with esophageal cancer who underwent esophageal surgery between January 2011 and December 2018 were included.

RESULTS

A total of 7039 patients were included in the final analysis. Among them, 100 patients (1.4%) experienced fatal respiratory adverse events (ARDS, 55 patients [0.8%]; respiratory failure, 45 patients [0.6%]). On multivariable logistic regression, residence in rural areas (vs. urban areas) at the time of surgery, open thoracotomy (vs. video-assisted thoracoscopic surgery), and lower annual case volume were associated with a higher prevalence of fatal respiratory adverse events. Moreover, postoperative fatal respiratory adverse events were related to increased in-hospital mortality, 1 year mortality, prolonged hospitalization, and increased total hospitalization costs.

CONCLUSION

In South Korea, 1.4% of patients experienced fatal respiratory events (ARDS or respiratory failure) after esophageal cancer surgery. Some factors were revealed as risk factors for fatal respiratory events, and fatal respiratory events worsened clinical outcomes after esophageal cancer surgery.

Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Robot-assisted minimally invasive esophagectomy (RAMIE) constitutes a newly developed surgical technique for the treatment of resectable esophageal cancer, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We performed a systematic review of the literature and compared the outcomes of RAMIE and open esophagectomy. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and hospital stays compared to open esophagectomy.

Abstract

Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): −187.08 mL, 95% CI: [−283.81, −90.35]) and shorter hospital stays (WMD: −9.22 days, 95% CI: [−14.39, −4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.

Incidence of upper extremity deep vein thrombosis in the retrosternal reconstruction after esophagectomy

Background

Upper extremity deep vein thrombosis (UEDVT) is relatively rare but cannot be negligible because it can cause fatal complications. Although it is reported that the occurrence rate of UEDVT has increased due to central venous catheter (CVC), cancer, and surgical invasion, there is still limited information for esophagectomy. The aim of this study was to evaluate the clinical factors, including CVC placement and thromboprophylaxis approach, as well as retrosternal space’s width as a predictive factor for UEDVT in patients receiving esophagectomy.

Methods

This study included 66 patients who underwent esophagectomy with retrosternal reconstruction using a gastric tube. All patients routinely underwent contrast-enhanced computed tomography (CT) on the 4th postoperative day. Low-molecular-weight-heparin (LMWH) was routinely administered by the 2nd postoperative day. To evaluate retrosternal space’s width, (a) The distance from sternum to brachiocephalic artery and (b) the distance from sternum to vertebra were measured by preoperative CT, and the ratio of (a) to (b) was defined as the width of retrosternal space.

Results

Among all patients, 11 (16.7%) suffered from UEDVT, and none was preoperatively received CVC placement, while 7 were inserted in non-UEDVT cases. Retrosternal space’s width in patients with UEDVT was significantly smaller than that in patients without UEDVT (0.17 vs. 0.26; P < 0.0001). A cutoff value of the width was 0.21, which has high sensitivity (87%) and specificity (82%) for UEDVT prediction, respectively.

Conclusion

The existence of CVC may not affect the development of UEDVT, but preoperative evaluation of retrosternal ratio may predict the occurrence of UEDVT.

Minimally invasive esophagectomy versus open esophagectomy: A systematic review and meta-analysis

The paradigm of the treatment of esophageal cancer has been changing with the increasing use of minimally invasive esophagectomy (MIE) in detriment of open esophagectomy (OE). We aimed to perform a meta-analysis to evaluate and compare these two techniques in terms of mortality and associated complications. The literature search was conducted in MEDLINE and U.S. National Library of Medicine Clinical Trials, considering eligible articles since 2015 to 2020. Clinical trials and observational studies were included. We presented results as mean differences with 95% confidence intervals and calculation of heterogeneity associated to the included studies. Thirty-one articles were included with a total of 34,465 participants diagnosed with esophageal adenocarcinoma or squamous cell carcinoma. MIE had tendency towards a decrease in 30- and 90- day mortality after surgery, but no statistically significative results were found. Major cardiovascular and respiratory complications were less frequent in the MIE group, despite high heterogeneity. Also, MIE might contribute to a decrease of minor post-operative complications, to an increase need of a second surgical intervention, to a greater risk for vocal cord lesions; but these results were not statistically significant. Additionally, no differences were found concerning risk of wound infection and for local and systemic recurrence. MIE may be more beneficial than OE, but these findings should be considered carefully.

Impact of co-morbidity on reoperation or death within 90 days of surgery for oesophageal cancer

Background

The impact of preoperative co-morbidity on postoperative outcomes in patients with oesophageal cancer is uncertain. A population-based and nationwide cohort study was conducted to assess the influence of preoperative co-morbidity on the risk of reoperation or mortality within 90 days of surgery for oesophageal cancer.

Methods

This study enrolled 98 per cent of patients who had oesophageal cancer surgery between 1987 and 2015 in Sweden. Modified Poisson regression models provided risk ratios (RRs) with 95 per cent confidence intervals (c.i.) to estimate associations between co-morbidity and risk of reoperation or death within 90 days of oesophagectomy. The RRs were adjusted for age, sex, educational level, pathological tumour stage, neoadjuvant therapy, annual hospital volume, tumour histology and calendar period of surgery.

Results

Among 2576 patients, 446 (17.3 per cent) underwent reoperation or died within 90 days of oesophagectomy. Patients with a Charlson Co-morbidity Index (CCI) score of 2 or more had an increased risk of reoperation or death compared with those with a CCI score of 0 (RR 1.78, 95 per cent c.i. 1.44 to 2.20), and the risk increased on average by 27 per cent for each point increase of the CCI (RR 1.27, 1.18 to 1.37). The RR was increased in patients with pulmonary disease (RR 1.66, 1.36 to 2.04), cardiac disease (RR 1.37, 1.08 to 1.73), diabetes (RR 1.50, 1.14 to 1.99) and cerebral disease (RR 1.40, 1.06 to 1.85).

Conclusion

Co-morbidity in general, and pulmonary disease, cardiac disease, diabetes and cerebral disease in particular, increased the risk of reoperation or death within 90 days of oesophageal cancer surgery. This highlights the value of tailored patient selection, preoperative preparation and postoperative care.

Long-term outcomes of endoscopic submucosal dissection and comparison to surgery for superficial esophageal squamous cancer: a systematic review and meta-analysis

AIM

The aim of this study was to investigate the long-term outcomes of endoscopic submucosal dissection (ESD) for superficial esophageal squamous cancer.

METHODS

A literature search was conducted using PubMed, ProQuest and Cochrane Library databases. Primary outcomes were overall survival, disease-specific survival and recurrence-free survival at 5 years. Secondary outcomes included adverse events, recurrence and metastasis. Hazard ratios were calculated based on time to events for survival analysis, and odds radios were used to compare discrete variables.

RESULTS

A total of 3796 patients in 21 retrospective studies, including 5 comparative studies for ESD and esophagectomy were enrolled. The invasion depth was 52.0% for M1-M2, 43.2% for M3-SM1 and 4.7% for SM2 or deeper. The 5-year survival rate was: overall survival 87.3%, disease-specific survival 97.7%, and recurrence-free survival 85.1%, respectively. Pooled local recurrence of ESD was 1.8% and metastasis was 3.3%. In terms of the comparison between ESD and esophagectomy, there was no difference in the overall survival (86.4% versus 81.8%, hazard ratio = 0.66, 95% CI = 0.39-1.11) as well as disease-specific and recurrence-free survival. In addition, ESD was associated with fewer adverse events (19.8 % versus 44.0%, odds ratio = 0.3, 95% CI = 0.23-0.39).

CONCLUSIONS

For superficial esophageal squamous cancer, ESD may be considered as the primary treatment of for mucosal lesions, and additional treatment should be available for submucosal invasive cancers.

Effectiveness of salvage radiotherapy for superficial esophageal Cancer after non-curative endoscopic resection

BACKGROUND

Endoscopic resection is widely used as an effective treatment for superficial esophageal cancer. However, the risk of lymph node metastasis increases in cases of muscularis mucosae or deeper invasion, for which additional treatment such as radiotherapy or surgery is required. Accordingly, the current study investigated the efficacy and toxicity of salvage radiotherapy after non-curative endoscopic resection as an organ preservation strategy.

METHODS

We retrospectively reviewed 37 esophageal cancer patients who received salvage radiotherapy after non-curative endoscopic resection. The pathological invasion depths were the muscularis mucosae, submucosal layer, and muscularis propria in 14, 22, and one patient, respectively. All patients received external beam radiotherapy. Among them, eight received intraluminal brachytherapy following external beam radiotherapy. Elective nodal irradiation was administered to all patients. Twenty-five patients received concurrent platinum and fluorouracil-based chemotherapy.

RESULTS

The median follow-up time was 74 months (range: 3-212). The 5-year progression-free survival and overall survival rates were 64 and 78%, respectively. No local or regional lymph node recurrence was observed. The causes of death included esophageal cancer in one patient, metachronous esophageal cancer in one patient, other malignancies in eight patients, and other causes in six patients. Late cardiac toxicities ≥ grade 3 were observed in six patients, one of whom died of arrhythmia.

CONCLUSIONS

Salvage radiotherapy after non-curative esophageal endoscopic resection is an effective treatment as an organ preservation strategy. Although muscularis mucosae and submucosal cancer have a high risk of lymph node metastasis, our results suggest that elective nodal irradiation contributes to reduced regional node metastases.

Risk factors for delirium after esophagectomy

INTRODUCTION

Postoperative delirium is a common complication after major surgical procedures and affects outcomes and long-term survival. We identified factors associated with postoperative delirium in patients undergoing esophagectomy.

METHODS

Retrospective cohort analysis of 378 patients undergoing esophagectomy. We examined the association between postoperative delirium (DSM-V) criteria with respect to baseline variables and postoperative complications.

RESULTS

Postoperative delirium was diagnosed in 64 (16.93%) patients and associated with increasing age (P < .05), chronic obstructive pulmonary disease (P = .07), pneumonia (P = .01), transfusion intraoperatively or within 72 hours of surgery (P < .001), and sepsis (P = .001). Unplanned intubation and increased length of stay (median, 14 days) were significant in patients with delirium (P = .001 and P < .001, respectively). In a secondary analysis, surgical technique and operative approach were associated with delirium. Modified McKeown (three-hole) esophagectomy was twice more likely to develop delirium compared with Ivor Lewis (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.03-4.23). The strongest association was found between delirium and open techniques (thoracotomy and laparotomy) as compared with minimally invasive techniques (thoracoscopy and laparoscopy) (OR, 2.66; 95% CI, 1.22-5.76). Survival was similar between both groups.

CONCLUSIONS

Postoperative delirium is common and associated with complications following esophagectomy. Identification of predisposing factors such as age and pre-existing pulmonary diseases and proper selection of surgical treatment may reduce delirium and improve surgical outcomes.

Neoadjuvant Chemoradiotherapy for Patients with cT3/Nearly T4 Esophageal Cancer: Is Sarcopenia Correlated with Postoperative Complications and Prognosis?

BACKGROUND

Since the clinical impact of sarcopenia on multimodal therapy for patients with esophageal cancer is not well understood, this study was conducted to determine the influence of sarcopenia on the efficacy of neoadjuvant chemoradiotherapy (NACRT) for locally advanced esophageal cancer.

METHODS

The skeletal muscle index was quantified at the level of the third lumbar vertebra on computed tomography images, and sarcopenia was defined as a skeletal muscle index that was less than the average for each gender. We compared treatment outcomes in patients with cT3 and nearly T4 thoracic esophageal squamous cell carcinoma between the sarcopenia group (n = 85) and the non-sarcopenia group (n = 72).

RESULTS

The 5-year survival rates were 33.4% in the non-sarcopenia group and 31.5% in the sarcopenia group; these differences were not significant. The prognosis of the patients with sarcopenia was worse than that of the patients without sarcopenia in the surgery-alone group, but there was no difference between patients with and without sarcopenia in the NACRT group.

CONCLUSIONS

NACRT could be a useful option for patients with locally advanced esophageal squamous cell carcinoma, even for those with sarcopenia, without increasing the incidence of morbidity and mortality.

Comparison of short-term outcomes between minimally invasive McKeown and Ivor Lewis esophagectomy for esophageal or junctional cancer: a systematic review and meta-analysis

Purpose

Minimally invasive esophagectomy is increasingly performed for esophageal or gastroesophageal junctional cancer, with advantages of improved perioperative outcomes in comparison with open esophagectomy. McKeown and Ivor Lewis are widely used procedures of minimally invasive esophagectomy, and there have been controversies on which one is preferred for patients with resectable esophageal or junctional cancer.

Patients and methods

This review was registered at the International Prospective Register of Systematic Reviews (number CRD42017075989). Studies in PubMed, Embase, Web of Science, the Cochrane Library, and ClinicalTrials.gov were thoroughly investigated. Eligible studies included prospective and retrospective studies evaluating short-term outcomes of minimally invasive McKeown esophagectomy (MIME) vs minimally invasive Ivor Lewis esophagectomy (MILE) in patients with resectable esophageal or junctional tumors. Main parameters included anastomotic leak and 30-day/in-hospital mortality. Overall incidence rates (ORs)/weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated by employing random-effects models.

Results

Fourteen studies containing 3,468 cases were included in this meta-analysis. Age, male sex, and American Joint Committee on Cancer (AJCC) stage between the 2 groups were not statistically different. MIME led to more blood loss, longer operating time, and longer hospital stay than MILE. MIME was associated with higher incidence of pulmonary complications (OR =1.96, 95% CI =1.28–3.00) as well as total anastomotic leak (OR =2.55, 95% CI =1.40–4.63), stricture (OR =2.07, 95% CI =1.05–4.07), and vocal cord injury/palsy (OR =5.62, 95% CI =3.46–9.14). In addition, the differences of R0 resection rate, number of lymph modes retrieved, blood transfusion rate, length of intensive care unit stay, incidence of cardiac arrhythmia, and Chyle leak between MIME and MILE were not statistically significant. Notably, incidence of severe anastomotic leak (OR =1.28, 95% CI =0.73–2.24) and 30-day/in-hospital mortality (OR =1.76, 95% CI =0.92–3.36) as well as 90-day mortality (OR =2.22, 95% CI =0.71–6.98) between the 2 procedures were also not significantly different.

Conclusion

This study suggests that MIME and MILE are comparable with respect to clinical safety. MILE may be a better option when oncologically and clinically suitable. MIME is still a safe alternative procedure when clinically indicated. However, this evidence is at risk for bias; randomized controlled trials are needed to validate or correct our results.

Prognosis of surgery combined with different adjuvant therapies in esophageal cancer treatment: a network meta-analysis

This network meta-analysis was conducted to assess whether the efficacy of surgery with adjuvant therapies, including radiotherapy (RT+S), chemotherapy (CT+S), and chemoradiotherapy (CRT+S) have better performance in esophageal cancer treatment and management. PubMed and EMBASE were used to search for relevant trials. Both conventional pair-wise and network meta-analyses were carried out. The surface under the cumulative ranking curve (SUCRA) was used to rank interventions based on the efficacy of the treatment method. As for 3-year overall survival (OS), CRT+S showed the highest efficacy (CRT+S vs.

SURGERY

HR=0.81, 95% CrI =0.73-0.90; CRT+S vs. CT+S: HR=0.82, 95% CrI =0.70-0.95; CRT+S vs. RT+S: HR=0.77, 95% CrI =0.62-0.95). For disease-free survival, CRT+S showed efficacy over CT+S ((HR =0.70, 95% CrI =0. 59-0.83). In conclusion, CRT+S showed a better performance for survival outcomes and ranks best among all therapies. The results of our study can provide guidance for medical decisions and treatment options that may help clinical practitioners improve the efficacy of EC treatment.

Treatment of Squamous Cell Carcinoma of the Esophagus Synchronously Associated with Head and Neck Cancer

BACKGROUND/AIM

The aim of this study was to clarify the treatment strategy for synchronous squamous cell carcinoma of the esophagus (ESCC) and head and neck cancer (HNC).

PATIENTS AND METHODS

Treatment outcomes of 91 patients with synchronous ESCC and HNC were evaluated. Thirty-eight patients received simultaneous definitive chemoradiotherapy (CRT) and 15 patients underwent simultaneous resection.

RESULTS

Among the patients who received simultaneous CRT, adverse events (grade 3-5) were recognized in 14 patients (40%), including one case of death due to aspiration pneumonia. Complete response was observed in 22 patients with ESCC (58%) and 19 patients with HNC (50%). The five-year survival rate was 44%. There were no in-hospital deaths after simultaneous resection; however, postoperative complications were recognized in 4 patients. The five-year OS was 70%.

CONCLUSION

The treatment of synchronous ESCC and HNC must be decided by adopting a strategy that is appropriate for each case. Both simultaneous CRT and simultaneous resection are feasible and effective treatment options.

Effects of a preoperative immune-modulating diet in patients with esophageal cancer: a prospective parallel group randomized study

PURPOSE

The aim of this pilot study was to investigate the effects of a preoperative immune-modulating diet (IMD) before thoracoscopic esophagectomy for patients with esophageal cancer.

METHODS

Thirty patients who were diagnosed with resectable esophageal cancer were assigned to two groups: the IMD (n = 15) and the standard liquid diet (SLD; n = 15) groups. We evaluated postoperative parameters, such as the incidence of complications and the postoperative levels of cytokines as the primary endpoints. The secondary endpoint was the length of hospital stay.

RESULTS

The peak levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-α appeared on postoperative day (POD) 1 and POD 2 in the IMD and SLD group, respectively. The peak level of C-reactive protein (CRP) appeared on POD 3 in both groups (IMD 9.9 mg/dL, SLD 15.2 mg/dL). Overall, TNF-α levels in the IMD group were lower than those in the SLD group (P = 0.033). Furthermore, IL-6 (P = 0.182) and CRP (P = 0.191) levels, and the incidence of postoperative pneumonia (7.1 vs. 26.7%; P = 0.330) tended to be lower in the IMD group than in the SLD group.

CONCLUSIONS

Preoperative IMD suppressed the elevation of the TNF-α levels after thoracoscopic esophagectomy in patients with esophageal cancer, although no different tendency was detected in terms of IL-6, CRP or postoperative complications.

Treatment results of two-stage operation for the patients with esophageal cancer concomitant with liver dysfunction

PURPOSE

The aim of this study was to clarify the usefulness of two-stage operation for the patients with esophageal cancer who have liver dysfunction.

METHODS

Eight patients with esophageal cancer concomitant with liver dysfunction who underwent two-stage operation were analyzed. The patients initially underwent an esophagectomy, a cervical esophagostomy and a tube jejunostomy, and reconstruction with gastric tube was performed after the recovery of patients' condition.

RESULTS

The average time of the 1(st) and 2(nd) stage operation was 410.0 min and 438.9 min, respectively. The average amount of blood loss in the 1(st) and 2(nd) stage operation was 433.5 ml and 1556.8 ml, respectively. The average duration between the operations was 29.8 days. The antesternal route was selected for 5 patients (62.5%) and the retrosternal route was for 3 patients (37.5%). In the 1(st) stage operation, no postoperative complications were observed, while, complications developed in 5 (62.5%) patients, including 4 anastomotic leakages, after the 2(nd) stage operation. Pneumonia was not observed through two-stage operation. No in-hospital death was experienced.

CONCLUSION

A two-stage operation might prevent the occurrence of critical postoperative complications for the patients with esophageal cancer concomitant with liver dysfunction.

Minimally invasive oesophagectomy versus open esophagectomy for resectable esophageal cancer: a meta-analysis

Background

Open esophagectomy (OE) is associated with significant morbidity and mortality. Minimally invasive oesophagectomy (MIO) reduces complications in resectable esophageal cancer. The aim of this study is to explore the superiority of MIO in reducing complications and in-hospital mortality than OE.

Methods

MEDLINE, Embase, Science Citation Index, Wanfang, and Wiley Online Library were thoroughly searched. Odds ratio (OR)/weighted mean difference (WMD) with a 95% confidence interval (CI) was used to assess the strength of association.

Results

Fifty-seven studies containing 15,790 cases of resectable esophageal cancer were included. MIO had less intraoperative blood loss, short hospital stay, and high operative time (P < 0.05) than OE. MIO also had reduced incidence of total complications; (OR = 0.700, 95% CI = 0.626 ~ 0.781, P_V < 0.05), pulmonary complications (OR = 0.527, 95% CI = 0431 ~ 0.645, P_V < 0.05), cardiovascular complications (OR = 0.770, 95% CI = 0.681 ~ 0.872, P_V < 0.05), and surgical technology related (STR) complications (OR = 0.639, 95% CI = 0.522 ~ 0.781, P_V < 0.05), as well as lower in-hospital mortality (OR = 0.668, 95% CI = 0.539 ~ 0.827, P_V < 0.05). However, the number of harvested lymph nodes, intensive care unit (ICU) stay, gastrointestinal complications, anastomotic leak (AL), and recurrent laryngeal nerve palsy (RLNP) had no significant difference.

Conclusions

MIO is superior to OE in terms of perioperative complications and in-hospital mortality.

The PER (Preoperative Esophagectomy Risk) Score: A Simple Risk Score to Predict Short-Term and Long-Term Outcome in Patients with Surgically Treated Esophageal Cancer

Esophageal resection in patients with esophageal cancer (EC) is still associated with high mortality and morbidity rates. We aimed to develop a simple preoperative risk score for the prediction of short-term and long-term outcomes for patients with EC treated by esophageal resection. In total, 498 patients suffering from esophageal carcinoma, who underwent esophageal resection, were included in this retrospective cohort study. Three preoperative esophagectomy risk (PER) groups were defined based on preoperative functional evaluation of different organ systems by validated tools (revised cardiac risk index, model for end-stage liver disease score, and pulmonary function test). Clinicopathological parameters, morbidity, and mortality as well as disease-free survival (DFS) and overall survival (OS) were correlated to the PER score. The PER score significantly predicted the short-term outcome of patients with EC who underwent esophageal resection. PER 2 and PER 3 patients had at least double the risk of morbidity and mortality compared to PER 1 patients. Furthermore, a higher PER score was associated with shorter DFS (P < 0.001) and OS (P < 0.001). The PER score was identified as an independent predictor of tumor recurrence (hazard ratio [HR] 2.1; P < 0.001) and OS (HR 2.2; P < 0.001). The PER score allows preoperative objective allocation of patients with EC into different risk categories for morbidity, mortality, and long-term outcomes. Thus, multicenter studies are needed for independent validation of the PER score.

Safety and benefit of curative surgical resection for esophageal squamous cell cancer associated with multiple primary cancers

BACKGROUND

Enhancements in surgical techniques have led to improved outcomes for esophageal cancer. Recent findings have showed that esophageal cancer is frequently associated with multiple primary cancers, and surgical resection is usually complicated in such cases. The aim of this study was to clarify the clinical significance of surgery for patients with esophageal squamous cell cancer associated with multiple primary cancers.

METHODS

The clinical outcomes of surgical resection for esophageal cancer were compared among 79 patients with antecedent and/or synchronous cancers (Multiple cancer group) and 194 patients without antecedent and/or synchronous cancers (Single cancer group).

RESULTS

The most common site of multiple primary cancers was the pharynx (36 patients; 29.7%), followed by the stomach (24 patients; 19.8%). The reconstruction method was more complicated in the Multiple cancer group as a result of the prolonged surgery time and increased blood loss. However, postoperative morbidity and overall survival (OS) did not differ between the two groups. After esophagectomy, metachronous cancers were observed in 26 patients, with 30 regions in total, and 93.1% were found to be curable. Sex was the only independent risk factors for developing metachronous cancer after esophagectomy.

CONCLUSIONS

The presence of antecedent and synchronous cancers complicates the surgical resection of esophageal cancer; however, no differences were found in the OS and postoperative morbidity between the two groups. Therefore, surgical intervention should be selected as a first-line treatment. Because second primary cancers are often observed in esophageal cancer, we recommend a close follow-up using esophagogastroduodenoscopy and contrast-enhanced computed tomography.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer

BACKGROUND

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections.

METHODS

The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure.

RESULTS

Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration.

CONCLUSION

Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems.

Is minimally invasive esophagectomy effective for preventing anastomotic leakages after esophagectomy for cancer? A systematic review and meta-analysis

Background

Compared with open esophagectomy (OE), minimally invasive esophagectomy (MIE) proves to have clear benefits in reducing the risk of pulmonary complications for patients with resectable esophageal cancer. The objectives of our study were to explore the superiority of MIE in reducing the occurrence of anastomotic leakages (ALs) when compared to OE.

Methods

A systematic review and meta-analysis was performed to assess the superiority of MIE on the occurrence of ALs over OE, by searching many sources (through December, 2014) such as Medline, Embase, Wiley Online Library, and Cochrane Library. Fixed-effects model was used to calculate summary odds ratios (ORs) to quantify associations between OE and MIE groups. Cochran’s Q and I² statistics were used to evaluate heterogeneity among studies.

Results

Among a total of 43 studies involving 5537 patients included in the meta-analysis, 2527 (45.6 %) cases underwent MIE and 3010 (54.4 %) cases underwent OE. Compared to patients undergoing OE, patients undergoing MIE did not have statistical significance in reduced occurrence of ALs (OR = 0.97, 95 % CI = 0.80–1.17). Insignificant reduced occurrence of ALs was not associated with anastomotic location (OR = 0.90, 95 % CI = 0.71–1.13) or anastomotic procedure (OR = 1.02, 95 % CI = 0.79–1.30).

Conclusions

More proofs are needed to clarify the strengths or weaknesses of MIE in preventing anastomotic leakages after esophagectomy for cancer. A largely randomized, controlled trial should be undertaken to resolve this contentious issue urgently.

Superiority of Minimally Invasive Oesophagectomy in Reducing In-Hospital Mortality of Patients with Resectable Oesophageal Cancer: A Meta-Analysis

Background

Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM).

Objective

The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM).

Data Sources

Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched.

Study Selection

Data of randomized and non-randomized clinical trials related to MIO versus OE were included.

Interventions

Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE.

Study Appraisal and Synthesis Methods

Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran’s Q and I² statistics.

Results

A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49).

Limitation

Most of the included studies were non-randomized case-control studies, with a diversity of study designs, demographics of participants and surgical intervention.

Conclusions

Minimally invasive oesophagectomy (MIO) has superiority over open oesophagectomy (OE) in terms of the occurrence of in-hospital mortality (IHM) and should be the first-choice surgical procedure in esophageal surgery.

Exposure to an atomic bomb explosion is a risk factor for in-hospital death after esophagectomy to treat esophageal cancer

Esophagectomy, one of the most invasive of all gastrointestinal operations, is associated with a high frequency of postoperative complications and in-hospital mortality. The purpose of the present study was to determine whether exposure to the atomic bomb explosion at Hiroshima in 1945 might be a preoperative risk factor for in-hospital mortality after esophagectomy in esophageal cancer patients. We thus reviewed the outcomes of esophagectomy in 31 atomic bomb survivors with esophageal cancer and 96 controls (also with cancer but without atomic bomb exposure). We compared the incidences of postoperative complications and in-hospital mortality. Of the clinicopathological features studied, mean patient age was significantly higher in atomic bomb survivors than in controls. Of the postoperative complications noted, atomic bomb survivors experienced a longer mean period of endotracheal intubation and higher incidences of severe pulmonary complications, severe anastomotic leakage, and surgical site infection. The factors associated with in-hospital mortality were exposure to the atomic bomb explosion, pulmonary comorbidities, and electrocardiographic abnormalities. Multivariate analysis revealed that exposure to the atomic bomb explosion was an independent significant preoperative risk factor for in-hospital mortality. Exposure to the atomic bomb explosion is thus a preoperative risk factor for in-hospital death after esophagectomy to treat esophageal cancer.

Clinicopathological characteristics of esophageal squamous cell carcinoma in patients younger than 50 years

PURPOSE

This study clarifies age differences in clinicopathologic characteristics and risk factor exposure of patients who have undergone esophagectomy for esophageal cancer (EC).

METHODS

Clinical results of esophagectomy were compared between 22 patients younger than 50 years of age (Group I) and 327 patients older than 50 years of age (Group II) with esophageal squamous cell carcinoma.

RESULTS

The two groups did not significantly differ in clinicopathological characteristics, including prognosis. Postoperative pulmonary complication incidence rates were 4.2 % (Group I) and 14.4 % (Group II). In Group I, the incidence of multiple ECs was 36.4 %, and association with head and neck cancer was 31.8 %, which were significantly higher than in Group II (13.4 %, p = 0.021; and 9.2 %, p = 0.015, respectively). Furthermore, the patients in Group I with multiple cancers were almost all heavy smokers and/or users of alcohol.

CONCLUSIONS

These results suggest that multiple upper aerodigestive tract cancers are associated with heavy exposure to risk factors in patients younger than 50 years of age.

Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures

BACKGROUND

Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS).

METHODS

Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement.

RESULTS

Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3).

CONCLUSIONS

This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.

Prognostic factors and causes of death in patients cured of esophageal cancer

BACKGROUND

The number of patients cured of esophageal cancer after esophagectomy is gradually increasing owing to advances in surgical techniques, perioperative management, and adjuvant therapies. This study assessed the clinical course and sought to identify the prognostic factors of these patients.

METHODS

A series of 220 consecutive patients who underwent esophagectomy and survived for more than 5 years with no relapse were enrolled. Survival analysis was performed using 25 variables including patient characteristics and operative and perioperative factors. Potential prognostic factors were identified by univariate and multivariate analyses, and the development of other primary cancers and the causes of death were retrospectively reviewed.

RESULTS

The overall 10-, 15-, and 20-year survival rates were 71.6, 50.1, and 32.2 %, respectively, with a median survival time of 180 months (range, 61-315 months). The negative independent prognostic factors identified were age at surgery [hazard ratio (HR), 1.05; P < .01], being male (HR, 2.62; P = .02), pulmonary comorbidities (HR, 2.03; P = .02), synchronous presence of other cancers (HR, 2.35; P < .01), colonic/jejunal interposition (HR, 1.76; P = .03), perioperative blood transfusion (HR, 1.92; P = .02), development of pulmonary complications (HR, 1.71; P = .02), and adjuvant radiotherapy (HR, 2.13; P = .01). Pulmonary diseases and other primary cancers were found to be the most common causes of death.

CONCLUSIONS

Careful follow-up including the surveillance of other primary cancers is required for long-term survivors of esophageal cancer after esophagectomy.

Technical improvement of total pharyngo-laryngo-esophagectomy for esophageal cancer and head and neck cancer

PURPOSE

Total pharyngo-laryngo-esophagectomy (PLE) is highly invasive, and the subsequent reconstruction is difficult. The purpose of this study was to clarify the techniques that can decrease the surgical stress and allow for safe reconstruction after this operation.

METHODS

The surgical method and clinical outcomes of total PLE were reviewed in 12 patients with either cervicothoracic esophageal cancer or double cancer of the esophagus and pharynx. Microscopic venous anastomosis was principally performed, and arterial anastomosis was added, if needed.

RESULTS

A narrow gastric tube was used in ten patients, including two patients who underwent free jejunal interposition, while the colon was used as the main reconstructed organ in two other patients. Staged operations were performed in three high-risk patients. All six patients treated after 2010 were able to undergo thoracoscopic and/or laparoscopic surgery. No critical postoperative complications developed, although minor anastomotic leakage developed in two patients who were successfully treated conservatively.

CONCLUSION

When performing PLE, it is important to decrease the surgical stress and ensure a reliable reconstruction by adopting techniques that are appropriate for each case, such as thoracoscopic and laparoscopic surgery, staged operations, microvascular anastomosis, and muscular flaps.

Clinical prognostic factors for locally advanced esophageal squamous carcinoma treated after definitive chemoradiotherapy

PURPOSE

Locally advanced esophageal cancers are generally treated with neoadjuvant chemoradiotherapy, followed by surgery in operable candidates. However, even if the patients were diagnosed as operable disease, surgery could not be performed on patients with poor condition or other comorbidity. In this case, definitive chemoradiotherapy (dCRT) is the other option for localized esophageal cancer. Therefore, the purpose of this study was to evaluate the efficacy and clinical prognostic factors for dCRT in locally advanced esophageal cancer.

MATERIALS AND METHODS

We conducted a review of patients who received dCRT for locally advanced squamous esophageal cancer from 2004 to 2010, focusing on stages III and IVa. All patients received at least two cycles of platinum-based chemotherapy during radiation, and all tumor burdens were included in the radiation field. The treatment results were analyzed for patterns of failure and prognostic factors associated with survival.

RESULTS

In total, 63 patients were enrolled in this study. The overall response rate was 84.1%. Relief from dysphagia after dCRT was achieved in 48 patients. The most frequent failure was local recurrence. The median overall survival (OS) was 23.0 months, and the 2-year survival rate was 45.4%. Similar results were observed for elderly study patients. Significant prognostic factors for OS were duration of smoking, high grade of dysphagia (score of 3 or 4), and shorter duration of progression-free and dysphagia-free survival. Maintenance chemotherapy after dCRT did not influence OS. However, "good risk" patients receiving maintenance chemotherapy showed better OS than those who did not receive maintenance chemotherapy (30.4 months vs. 12.0 months, p=0.002).

CONCLUSION

dCRT has a major role in improving survival and palliation of dysphagia in inoperable advanced esophageal cancer, even in elderly patients. Maintenance chemotherapy after dCRT may be effective in prolonging survival in "good risk" patients.

Gender differences in prognosis after esophagectomy for esophageal cancer

PURPOSE

The purpose of this study was to clarify the gender differences in the prognosis, as well as mortality and morbidity, of patients who have undergone esophagectomy for esophageal cancer.

METHODS

The clinical results of esophagectomy were compared between 975 male and 156 female patients with esophageal cancer.

RESULTS

The male to female ratios of cervical and thoracic esophageal cancer were 1.87 and 7.38, respectively (P < 0.01). The incidence of preoperative comorbidities was 32.4 and 17.4 %, respectively, and the rates of both tobacco and alcohol abuse were significantly lower in the females than in the males. The mortality rate was lower in the females (3.8 %) than in the males (5.7 %), although the differences were not significant. The overall survival was significantly better in the female than in the male patients (P = 0.039). The 5- and 10-year overall survival rates were 32.6 and 20.5 % in the males and 39.5 and 32.5 % in the females, respectively. A multivariate analysis revealed gender to be an independent prognostic factor. However, no significant differences were recognized in disease-specific survival.

CONCLUSIONS

These results suggest that the prognosis of females with esophageal cancer is better than that of males after esophagectomy, most likely due to multiple clinical factors, such as a more favorable lifestyle and general status.

Surgical resection for esophageal cancer synchronously or metachronously associated with head and neck cancer

BACKGROUND

Esophageal cancer is frequently associated with head and neck cancer, and esophagectomy is usually difficult in such a case. The purpose of this study was to clarify the clinical significance of esophagectomy for patients with esophageal cancer associated either synchronously or metachronously with head and neck cancer.

METHODS

The clinical outcomes of surgical resections for esophageal cancer were compared between 26 patients with head and neck cancer (double cancer group) and 176 without head and neck cancer (control group).

RESULTS

Staged operations were performed in 5 patients in the double cancer group, while microvascular anastomosis as well as a muscle flap was added for 3 and 4 patients, respectively. The mortality and morbidity of the double cancer group were 0 and 35 %, respectively, which were not significantly different from those of the control group (3 and 31 %, respectively). There were no significant differences in overall survival in the double cancer and control groups, which had 5-year survival rates of 59 and 49 %, respectively.

CONCLUSIONS

Esophagectomy can be an effective treatment when techniques are adopted that are appropriate for each case, such as staged operations, muscular flaps, and microvascular anastomosis, even in patients with double cancers of the esophagus and the head and neck.

Anesthetic management for esophageal resection

Surgical resection remains a standard treatment option for localized esophageal cancer. Surgical approaches to esophagectomy include transhiatal and transthoracic techniques as well as minimally invasive techniques that have been developed to reduce the morbidities associated with laparotomy and thoracotomy incisions. The perioperative mortality for esophagectomy remains high with cardiopulmonary and anastomotic complications as the most frequent and serious morbidities. This article reviews the management of patients presenting for esophagectomy, with a focus on evidence-based anesthetic and perioperative approaches for improving outcomes.

Oesophagectomy rates and post-resection outcomes in patients with cancer of the oesophagus and gastro-oesophageal junction: a population-based study using linked health administrative linked data

Background

Hospital performance is being benchmarked increasingly against surgical indicators such as 30-day mortality, length-of-stay, survival and post-surgery complication rates. The aim of this paper was to examine oesophagectomy rates and post-surgical outcomes in cancers of the oesophagus and gastro-oesophageal junction and to determine how the addition of gastro-oesophageal cancer to oesophageal cancer impacts on these outcomes.

Methods

Our study population consisted of patients with a primary invasive oesophageal or gastro-oesophageal cancer identified from the NSW Cancer Registry from July 2000-Dec 2007. Their records were linked to the hospital separation data for determination of resection rates and post-resection outcomes. We used multivariate logistic regression analyses to examine factors associated with oesophagectomy and post-resection outcomes. Cox-proportional hazard regression analysis was used to examine one-year cancer survival following oesophagectomy.

Results

We observed some changes in resection rates and surgical outcomes with the addition of gastro-oesophageal cancer patients to the oesophageal cancer cohort. 14.6% of oesophageal cancer patients and 26.4% of gastro-oesophageal cancer patients had an oesophagectomy; an overall oesophagectomy rate of 18.2% in the combined cohort. In the combined cohort, oesophagectomy was associated with younger age, being male and Australian-born, having non-metastatic disease or adenocarcinoma and being admitted in a co-located hospital. Rates of length-of-stay >28 days (20.9% vs 19.7%), 30-day mortality (3.8% vs 2.7%) and one-year survival post-surgery (24.5% vs 23.1%) were similar between oesophageal cancer alone and the combined cohort; whilst 30-day complication rates were 21.5% versus 17.0% respectively. Some factors statistically associated with post-resection complication in oesophageal cancer alone were not significant in the overall cohort. Poorer post-resection outcomes were associated with some patient (older age, birthplace) and hospital-related characteristics (fiscal sector, area health service).

Conclusion

Outcomes following oesophagectomy in oesophageal and gastro-oesophageal cancer patients in NSW are within world benchmarks. Our study demonstrates that the inclusion of gastro-oesophageal cancer did alter some outcomes compared to analysis based solely on oesophageal cancer. As such, care must be taken with analyses based on administrative health data to capture all populations eligible for treatment and to understand the contribution of these subpopulations to overall outcomes.

Esophagogastric junction adenocarcinoma: multivariate analyses of surgical morbi-mortality and adjuvant therapy

BACKGROUND

In recent years the literature has recorded a progressive increase in the prevalence of adenocarcinoma of the esophagogastric junction. Several factors can interfere with the morbidity and mortality of surgical treatment.

AIM

Non-randomized retrospective study of prognostic factors of operated patients by adenocarcinoma of esophagogastric junction, with or without post-operative chemotherapy and radiotherapy.

METHODS

Medical records were reviewed from patients treated at university hospital in the period of 1989 and 2009, to obtain data about pre and postoperative treatment. Cox's univariate and multivariate regression analysis of risk factors for prognostic of these patients were done with level of significance of 5 %.

RESULTS

Were reviewed 103 patients distributed as: 1) 78 (75.7%) patients without adjuvant therapy, and 2) 25 (24.3%) with it. All patients underwent surgical resection with curative intent. Cox's multivariate regression analysis of all patients showed that: lymphnode invasion N2 had greater risk of death in 5.9 times; broncopneumonia, in 11.4 times; tumoral recurrence during clinical following greater in 3.8 times.

CONCLUSION

Tumoral recurrence, lymphnode metastasis and broncopneumonia in the postoperative period were factors of bad prognosis and contributed significantly to increase morbimortality and decrease global survival.

Esophagogastric junction adenocarcinoma: multivariate analyses of surgical morbi-mortality and adjuvant therapy

BACKGROUND

In recent years the literature has recorded a progressive increase in the prevalence of adenocarcinoma of the esophagogastric junction. Several factors can interfere with the morbidity and mortality of surgical treatment.

AIM

Non-randomized retrospective study of prognostic factors of operated patients by adenocarcinoma of esophagogastric junction, with or without post-operative chemotherapy and radiotherapy.

METHODS

Medical records were reviewed from patients treated at university hospital in the period of 1989 and 2009, to obtain data about pre and postoperative treatment. Cox's univariate and multivariate regression analysis of risk factors for prognostic of these patients were done with level of significance of 5 %.

RESULTS

Were reviewed 103 patients distributed as: 1) 78 (75.7%) patients without adjuvant therapy, and 2) 25 (24.3%) with it. All patients underwent surgical resection with curative intent. Cox's multivariate regression analysis of all patients showed that: lymphnode invasion N2 had greater risk of death in 5.9 times; broncopneumonia, in 11.4 times; tumoral recurrence during clinical following greater in 3.8 times.

CONCLUSION

Tumoral recurrence, lymphnode metastasis and broncopneumonia in the postoperative period were factors of bad prognosis and contributed significantly to increase morbimortality and decrease global survival.

Endoscopic therapy for Barrett's esophagus: a review of its emerging role in optimal diagnosis and endoluminal therapy

Barrett's esophagus (BE) is a premalignant lesion known to sequentially progress to esophageal adenocarcinoma. Management of BE has changed significantly over the last 5 years with the development of endoscopic resection and ablation, which has replaced esophagectomy as the treatment of choice in BE with high-grade dysplasia. The aim of this review is to discuss the details of these new endotherapies in regards to response and durability and to define the role of these new therapies in the current management of BE.

Postoperative mortality and complications

Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. There is emerging work on quantifying frailty as a further risk factor for perioperative complication and mortality as well as need for higher level of care after discharge from hospital. Important postoperative complications include sepsis and kidney injury. Preventing, detecting and managing complications and mortality is the greatest challenge facing those caring for surgical patients, including anaesthetists. Evidence for the long term effects of perioperative complications adds further importance to minimizing perioperative complications. Newer approaches in patient care, particularly co-management during the postoperative phase by different specialities are emerging. Managing high-risk patients should also be enhanced with greater surveillance and more rapid and appropriate response; ensuring we do not fail to rescue our patients.

Clinical significance of salvage esophagectomy for remnant or recurrent cancer following definitive chemoradiotherapy

BACKGROUND

The purpose of this study was to clarify the effect of preoperative chemoradiotherapy (CRT) for esophageal cancer on the postoperative course, and to determine the clinical significance of salvage esophagectomy after definitive CRT.

METHODS

Based on their preoperative treatment, 477 patients with esophageal cancer were classified into three groups: 253 patients who received surgery alone (Group I), 197 who received planned CRT (30-45 Gy, Group II), and 27 who received a salvage esophagectomy (radiation ≥60 Gy, Group III).

RESULTS

Postoperative complications developed in 25, 40, and 59% of the patients in Groups I, II, and III, respectively, with pulmonary complications developing in 10, 15, and 30%, and anastomotic leakage developing in 13, 23, and 37%, respectively. Mortality rates were 2.4, 2.0, and 7.4%, respectively. Multivariate analysis revealed preoperative therapy to be an independent factor associated with postoperative risks: the odds ratios (ORs) of Groups II and III compared to Group I were 1.8 and 4.0 for pulmonary complications, while they were 1.9 and 2.8, respectively, for anastomotic leakage. No critical complications developed in the 14 patients who received salvage surgery performed with strict surgical indications after 2005. The survival of Group III was not significantly different from that of Groups I and II. Most patients who received an R1/R2 resection after definitive CRT died within 2 years after salvage surgery.

CONCLUSIONS

Preoperative CRT is associated with postoperative complications especially in patients with R2 resection, while long-term survival can be achieved after R0 resections. Salvage surgery should be considered for carefully selected patients in whom R0 resection can be achieved.