Evaluation of urgent esophagectomy in esophageal perforation

Emergency esophagectomy: Experience of a high volume esophageal cancer center

Objective

The objective of the study was to review the experience of dealing oncological emergency esophagectomies at a dedicated Cancer hospital.

Methods

We performed a retrospective review of data of eleven esophagectomies at the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (SKMCH&RC) Pakistan, from 1st January, 2009 to 30th June, 2019. Out of 590 oncological esophagectomies, eleven patients had emergency resection. We collected the data of demographics, primary disease, comorbidities, location of tumor and perforation, cause of perforations, radiological and endoscopic findings, clinical findings and follow-up visits after discharge. Data was analyzed by SPSS version 21 for windows.

Result

All 11 patients out of five hunded ninety had esophageal cancer. At the time of initial staging, eight (72%) had locally advanced stage (stage III and IV). Open transhiatal approach was used in six (55%) patients, and the rest had three stage esophagectomies. Primary reconstructions with gastric conduit were performed in all, except in two (18%) patients, Respiratory complications were the most common of the encountered complications, seven (63%) of the patients had palliative resection. Ninety day mortality was observed in 3(27.3%) patients. On long term follow up, six patients had recurrence, with median Disease-Free Survival (DFS) 5.88 months and Median Overall Survival (OS) was 6.37 months. Out of 11, only three patients are alive without disease, while one patient is lost during follow-up.

Conclusion

Emergency esophagectomy is a lifesaving procedure; there should be multidisciplinary team approach towards the management. Early diagnosis and management is of paramount importance.

Impact of Different Histopathological Factors on Recurrence and Survival in Operated Carcinoma Esophagus

Background Even with radical surgery, a significant percentage of patients of esophageal cancer experience recurrent disease.

Aims The aim of the current study is to define the impact of different histopathological factors on the recurrence and survival in carcinoma esophagus following surgery.

Materials and Methods A retrospective review of 182 patients of esophageal carcinoma, operated between January 2011 and December 2016, was done. In our study, 92 patients underwent upfront surgery and 90 took neo-adjuvant/perioperative treatment before planned surgery. To compare the proportion between two groups, chi-square test was used and to compare the median between the two groups, Mann—Whitney U test was used. Factors affecting the survival were analyzed using the Kaplan–Meier survival curve to compare the median survival time across groups log rank (Mantel–Cox) test was used.

Results Out of 182 patients, 55 patients developed recurrences, in which 19 were loco-regional and 36 were systemic. Patients with lymph node-positive disease on final histopathology had more recurrence than lymph node-negative (39.74%, 31/78) versus (23%, 24/104), p = 0.01 (significant). Patients with features such as PNI-positive, poor differentiation, lymph node-positive, ENE, and higher stage disease had statistically significant, lower DFS and OS with p-value < 0.05. Patients with adenocarcinoma histology had more systemic recurrences and statistically significant lower DFS than SCC with p-value < 0.05.

Conclusions Systemic recurrences are more common. PNI, ENE, grade, lymph node-positive disease, and higher pathologic stage had statistically significant negative impact on both DFS and OS. On multivariate analysis, whereas ENE had an impact on DFS alone.

Treatment mode and prognosis of esophageal perforation after radiotherapy in patients with esophageal carcinoma

Objective

Retrospectively analyzed the esophageal carcinoma (EC) patients with esophageal perforation (EP) after radiotherapy to discuss the treatment and prognosis.

Methods

Data of patients with EC who had EP after radiotherapy in Hebei Cancer Hospital were collected from 2001 to 2020 and retrospectively analyzed. All analyses were performed using SPSS Statistics for Windows, version 18. 0 (SPSS Inc., Chicago, Ill., USA). P values less than 0.05 were considered statistically significant.

Results

A total of 94 patients with EC were enrolled, among which 72 were males and 22 were females, with a median age of 62 (38-82) years. The tumor was located in the upper thoracic in 45 patients, middle thoracic in 45 patients, and lower thoracic in 4 patients. There were 30 cases of tracheoesophageal fistula (TEF) and 64 cases of esophagomediastinal fistula (EMF). All patients died within 11 months (median: two months) after EP. After EP, 48 patients were treated by tube feeding (include nasal feeding and gastrostomy), 26 patients by esophageal stenting, and 20 patients by fluid infusion therapy, and their one, three, and six months survival rates after EP were 81.3%, 31.3%, and 12.5% (P = 0.000). In the TEF group, the one, three, and six month survival rates after EP of tube feeding, esophageal stenting and fluid infusion groups were 88.2%, 17.6%, 11.8%; 45.5%, 27.3%, 0%; and 50.0%, 50.0%, 0% (P = 0.345). In the EMF group, the one, three, and six months survival rates after EP of this three groups were 77.4%, 38.7%, 12.9%; 26.7%, 20.0%, 6.7%; and 22.2%, 11.1%, 0% (P=0.002), respectively.

Conclusion

Most patients with EP after radiotherapy died within six months, with low survival and poor prognosis. Tube feeding therapy can achieve relatively good survival, especially for patients with EMF. The survival of patients treated by tube feeding therapy is significantly better than the survival of those treated by other methods.

Metastatic Esophageal Carcinoma: Prognostic Factors and Survival

BACKGROUND

Worldwide, esophageal cancer is the eighth most common cancer and the sixth leading cause of cancer-related death. At initial diagnosis, about 50% of esophageal cancer patients present with metastasis. The prognosis of metastatic esophageal cancer is poor with 5-year survival rate of less than 5%.

METHODS

This is a retrospective study of stage IV esophageal cancer patients registered at Clinical Oncology and Nuclear Medicine department and Oncology Center Mansoura University in the period from 2009 to 2018 inclusive. Eligibility criteria were all pathologically proven stage IV esophageal cancer patients. The medical files of patients were reviewed.

RESULTS

Most patients were ≥ 50 years (67.8%) with male predominance (76.7%). Middle third was the most common site of primary tumor (38.9%). Squamous cell carcinoma was more common with incidence of grade 3 (40%). T3-4 lesion was recorded in 61.1% and node positive in 66.7%. As regards metastasis; liver was the most common one (45.5%) followed by lung (30%). One-year survival rate was 25.6% with median survival time of 8 months. Multivariate analysis indicated that age (p = 0.03), site (p = 0.04), grade of primary tumor (p = 0.049), T classification (p = 0.0038), ECOG PS (p = 0.046), site (p = 0.026), and number of metastasis (p = 0.04) significantly affect prognosis while sex (p = 0.74) and histologic type (p = 0.94) do not.

CONCLUSION

Metastatic esophageal carcinoma is a disease of poor prognosis especially in patients with the following criteria: old age, lower third location, high grade and large tumors, poor performance status, multiple sites of metastasis and presence of bone secondaries.

Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis

<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of &#x3c;60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this associ­ation.

Is Esophagectomy for Benign Conditions Benign?

BACKGROUND

Outcomes data on esophagectomy performed for benign conditions is scarce. Using the National Surgical Quality Improvement Program database, we sought to analyze outcomes of esophagectomy performed for benign conditions.

METHODS

The National Surgical Quality Improvement Program database was queried for all esophagectomies performed from 2005 to 2015. Outcomes for benign conditions were analyzed and compared with outcomes for malignant conditions.

RESULTS

Esophagectomy was performed in 7,477 patients during the study period. Of those, 6,762 underwent esophagectomy for malignant conditions and 715 for benign conditions. For patients with benign conditions, reconstruction was performed using gastric conduit in 631 and colon/intestine in 84. The anastomosis was intrathoracic in 420 and cervical in 295. Benign esophagectomies were more likely to be emergent (10.1% vs 0.4%, p < 0.001). In addition, these patients had a longer hospital length of stay (17.2 days vs 14.5 days, p < 0.001) and higher occurrence of Clavien-Dindo grade IV complications (25% vs 20%, p = 0.003). Mortality was similar at 4%. In patients with benign conditions, reconstruction with colon/intestine had higher occurrence of Clavien-Dindo Grade IV complications (37% vs 23%, p = 0.006), surgical wound infections (33% vs 16%, p < 0.001), and death (10% vs 4%, p = 0.017) compared with gastric reconstruction. Site of anastomosis did not affect outcomes.

CONCLUSIONS

Benign esophagectomies are associated with significant morbidity. Although the site of the anastomosis does not alter outcomes, use of colon/intestine conduit should be pursued with caution.

Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review

Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.

PROGNOSTIC FACTORS AND SURVIVAL ANALYSIS IN ESOPHAGEAL CARCINOMA

Background:

Despite recent advances in diagnosis and treatment, esophageal cancer still has high mortality. Prognostic factors associated with patient and with disease itself are multiple and poorly explored.

Aim:

Assess prognostic variables in esophageal cancer patients.

Methods:

Retrospective review of all patients with esophageal cancer in an oncology referral center. They were divided according to histological diagnosis (444 squamous cell carcinoma patients and 105 adenocarcinoma), and their demographic, pathological and clinical characteristics were analyzed and compared to clinical stage and overall survival.

Results:

No difference was noted between squamous cell carcinoma and esophageal adenocarcinoma overall survival curves. Squamous cell carcinoma presented 22.8% survival after five years against 20.2% for adenocarcinoma. When considering only patients treated with curative intent resection, after five years squamous cell carcinoma survival rate was 56.6 and adenocarcinoma, 58%. In patients with squamous cell carcinoma, poor differentiation histology and tumor size were associated with worse oncology stage, but this was not evidenced in adenocarcinoma.

Conclusion:

Weight loss (kg), BMI variation (kg/m²) and percentage of weight loss are factors that predict worse stage at diagnosis in the squamous cell carcinoma. In adenocarcinoma, these findings were not statistically significant.

Outcome of stent grafting for esophageal perforations: single-center experience

BACKGROUND

Recent studies showed that stent grafting is a promising technique for treatment of esophageal perforation. However, the evidence of its benefits is still scarce.

METHODS

Forty-three consecutive patients underwent stent grafting for esophageal perforation at the Oulu University Hospital, Finland. The main endpoints of this study were early and mid-term mortality. Secondary outcome endpoints were the need of esophagectomy and additional surgical procedures on the esophagus and extraesophageal structures.

RESULTS

Patients' mean age was 64.6 ± 13.4 years. The mean delay to primary treatment was 23 ± 27 h. The most frequent cause of perforation was Boerhaave's syndrome (46.5%). The thoraco-abdominal segment of the esophagus was affected in 58.1% of cases. Minor primary procedures were performed in 25 patients (58.1%) and repeat surgical procedures in 23 patients (53.5%). Forty-nine repeat stent graftings were performed in 22 patients (50%). Two patients (4.7%) underwent esophagectomy, one for unrelenting preprocedural stricture of the esophagus and another for persistent leakage of a perforated esophageal carcinoma. The mean length of stay in the intensive care unit was 6.0 ± 7.5 days and the in-hospital stay was 24.3 ± 19.6 days. In-hospital mortality was 4.6%. Three-year survival was 67.2%.

CONCLUSIONS

Stent grafting seems to be an effective less invasive technique for the treatment of esophageal perforation. Repeat stent grafting and procedures on the pleural spaces are often needed to control the site of perforation and for debridement of surrounding infected structures. Stent grafting allows the preservation of the esophagus in most of patients. The mid-term survival of these patients is suboptimal and requires further investigation.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.