1
|
Davies AR, Sabharwal S, Liddle AD, Zamora-Talaya B, Rangan A, Reilly P. Patient reported outcomes following total shoulder arthroplasty and hemiarthroplasty: An analysis of data from the National Joint Registry. J Shoulder Elbow Surg 2024:S1058-2746(24)00194-0. [PMID: 38522778 DOI: 10.1016/j.jse.2024.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are used in the management of end stage glenohumeral arthritis. Improvement in shoulder function and resolution of symptoms are high priorities for patients. The aim of this study was to compare patient-reported outcome measures (PROMs) following TSA and HA. METHOD Records from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man were linked to the PROMs dataset. The study included anatomical shoulder arthroplasties performed for osteoarthritis in patients with an intact rotator cuff. Patients with preoperative and postoperative Oxford Shoulder Scores (OSSs) were included. The improvement in OSS at 6 months and 5 years, and the trend in scores over time were analyzed for each prosthesis. A cohort of 2,002 patients were matched on 10 variables using propensity scores. OSSs at 6 months following TSA versus HA were compared in the matched sample. RESULTS There was a significant improvement in the OSS in both groups (p<0.001). At 6 months the OSSs were superior following TSA compared to HA (median 42 vs 36, p<0.001). The median score at 5 years was 44 following TSA and 35 following HA. Score distributions were skewed towards the maximum score. The highest possible score (48) was achieved in 28% (134/478) of TSAs and 9% (20/235) of HAs at 5 years. The improvement in the preoperative to 6-month OSS reached the minimal clinically important difference of 5.5 in 92% (1653/1792) of TSAs and 80% (416/523) of HAs. At 5 years this improvement was maintained in 91% (339/374) of TSAs and 78% (136/174) of HAs. CONCLUSION TSA resulted in superior OSSs at 6 months in patients with osteoarthritis. The median OSS improved from 6 months to 5 years following TSA, however there was a small decline in scores following HA. A ceiling effect was shown in the OSS following TSA at 5 years.
Collapse
Affiliation(s)
| | - Sanjeeve Sabharwal
- Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust
| | - Alexander D Liddle
- Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust; Department of Surgery and Cancer, Imperial College London
| | | | - Amar Rangan
- Department of Health Sciences, University of York
| | - Peter Reilly
- Department of Bioengineering, Imperial College London; Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust
| |
Collapse
|
2
|
Davies AR, Sabharwal S, Liddle AD, Zamora B, Rangan A, Reilly P. The risk of revision is higher following shoulder hemiarthroplasty compared with total shoulder arthroplasty for osteoarthritis: a matched cohort study of 11,556 patients from the National Joint Registry, UK. Acta Orthop 2024; 95:73-85. [PMID: 38289339 PMCID: PMC10828514 DOI: 10.2340/17453674.2024.39916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/20/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are used in the management of osteoarthritis of the glenohumeral joint. We aimed to determine whether TSA or HA resulted in a lower risk of adverse outcomes in patients of all ages with osteoarthritis and an intact rotator cuff and in a subgroup of patients aged 60 years or younger. PATIENTS AND METHODS Shoulder arthroplasties recorded in the National Joint Registry, UK, between April 1, 2012 and June 30, 2021, were linked to Hospital Episode Statistics in England. Elective TSAs and HAs were matched on propensity scores based on 11 variables. The primary outcome was all-cause revision. Secondary outcomes were combined revision/non-revision reoperations, 30-day inpatient complications, 1-year mortality, and length of stay. 95% confidence intervals (CI) were reported. RESULTS 11,556 shoulder arthroplasties were included: 7,641 TSAs, 3,915 HAs. At 8 years 95% (CI 94-96) of TSAs and 91% (CI 90-92) of HAs remained unrevised. The hazard ratio (HR) varied across follow-up: 4-year HR 2.7 (CI 1.9-3.5), 8-year HR 2.0 (CI 0.5-3.5). Rotator cuff insufficiency was the most common revision indication. In patients aged 60 years or younger prosthesis survival at 8 years was 92% (CI 89-94) following TSA and 84% (CI 80-87) following HA. CONCLUSION The risk of revision was higher following HA in patients with osteoarthritis and an intact rotator cuff. Patients aged 60 years and younger had a higher risk of revision following HA.
Collapse
Affiliation(s)
| | - Sanjeeve Sabharwal
- Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust
| | - Alexander D Liddle
- Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust; Department of Surgery and Cancer, Imperial College London
| | | | - Amar Rangan
- Department of Health Sciences, University of York, UK
| | - Peter Reilly
- Department of Bioengineering, Imperial College London; Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust
| |
Collapse
|
3
|
Moore JL, Santaolalla A, Van Hemelrijck M, North B, Davies AR. Reply to R. Sun et al. J Clin Oncol 2024; 42:367-368. [PMID: 37988643 DOI: 10.1200/jco.23.02131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Jonathan L Moore
- Jonathan L. Moore, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; Aida Santaolalla, PhD, Mieke Van Hemelrijck, PhD, and Bernard North, PhD, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; and Andrew R. Davies, MD, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Aida Santaolalla
- Jonathan L. Moore, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; Aida Santaolalla, PhD, Mieke Van Hemelrijck, PhD, and Bernard North, PhD, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; and Andrew R. Davies, MD, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Mieke Van Hemelrijck
- Jonathan L. Moore, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; Aida Santaolalla, PhD, Mieke Van Hemelrijck, PhD, and Bernard North, PhD, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; and Andrew R. Davies, MD, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Bernard North
- Jonathan L. Moore, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; Aida Santaolalla, PhD, Mieke Van Hemelrijck, PhD, and Bernard North, PhD, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; and Andrew R. Davies, MD, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Andrew R Davies
- Jonathan L. Moore, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; Aida Santaolalla, PhD, Mieke Van Hemelrijck, PhD, and Bernard North, PhD, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom; and Andrew R. Davies, MD, FRCS, Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| |
Collapse
|
4
|
Knight W, Moore JL, Whyte GP, Zylstra J, Lane AM, Pate J, Gervais-Andre L, Maisey N, Hill M, Tham G, Lagergren J, Kelly M, Baker C, Van Hemelrijck M, Goh V, Gossage J, Browning M, Davies AR. Prehabilitation exercise before oesophagectomy: long-term follow-up of patients declining/withdrawing from the program. Br J Surg 2023; 110:1668-1672. [PMID: 37611139 DOI: 10.1093/bjs/znad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/29/2023] [Accepted: 07/21/2023] [Indexed: 08/25/2023]
Affiliation(s)
- William Knight
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | | | - Greg P Whyte
- School of Sports and Exercise Sciences, Liverpool John Moore's University, Liverpool, UK
- Centre for Health and Human Performance, London, UK
| | - Janine Zylstra
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Sports and Exercise Sciences, Liverpool John Moore's University, Liverpool, UK
| | - Andrew M Lane
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - James Pate
- Centre for Health and Human Performance, London, UK
| | | | - Nick Maisey
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - Mark Hill
- Department of Oncology, Maidstone and Tunbridge Wells NHS Trust Hospitals, Maidstone, UK
| | - Gemma Tham
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - Jesper Lagergren
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mark Kelly
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | - Cara Baker
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | | | - Vicky Goh
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | - James Gossage
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mike Browning
- Department of Oncology, Maidstone and Tunbridge Wells NHS Trust Hospitals, Maidstone, UK
| | - Andrew R Davies
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
Withey SJ, Owczarczyk K, Grzeda MT, Yip C, Deere H, Green M, Maisey N, Davies AR, Cook GJ, Goh V. Association of dynamic contrast-enhanced MRI and 18F-Fluorodeoxyglucose PET/CT parameters with neoadjuvant therapy response and survival in esophagogastric cancer. Eur J Surg Oncol 2023; 49:106934. [PMID: 37183047 PMCID: PMC10769883 DOI: 10.1016/j.ejso.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 04/17/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Better predictive markers are needed to deliver individualized care for patients with primary esophagogastric cancer. This exploratory study aimed to assess whether pre-treatment imaging parameters from dynamic contrast-enhanced MRI and 18F-fluorodeoxyglucose (18F-FDG) PET/CT are associated with response to neoadjuvant therapy or outcome. MATERIALS AND METHODS Following ethical approval and informed consent, prospective participants underwent dynamic contrast-enhanced MRI and 18F-FDG PET/CT prior to neoadjuvant chemotherapy/chemoradiotherapy ± surgery. Vascular dynamic contrast-enhanced MRI and metabolic 18F-FDG PET parameters were compared by tumor characteristics using Mann Whitney U test and with pathological response (Mandard tumor regression grade), recurrence-free and overall survival using logistic regression modelling, adjusting for predefined clinical variables. RESULTS 39 of 47 recruited participants (30 males; median age 65 years, IQR: 54, 72 years) were included in the final analysis. The tumor vascular-metabolic ratio was higher in patients remaining node positive following neoadjuvant therapy (median tumor peak enhancement/SUVmax ratio: 0.052 vs. 0.023, p = 0.02). In multivariable analysis adjusted for age, gender, pre-treatment tumor and nodal stage, peak enhancement (highest gadolinium concentration value prior to contrast washout) was associated with pathological tumor regression grade. The odds of response decreased by 5% for each 0.01 unit increase (OR 0.95; 95% CI: 0.90, 1.00, p = 0.04). No 18F-FDG PET/CT parameters were predictive of pathological tumor response. No relationships between pre-treatment imaging and survival were identified. CONCLUSION Pre-treatment esophagogastric tumor vascular and metabolic parameters may provide additional information in assessing response to neoadjuvant therapy.
Collapse
Affiliation(s)
- Samuel J Withey
- Department of Radiology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Kasia Owczarczyk
- Department of Clinical Oncology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mariusz T Grzeda
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom
| | - Connie Yip
- Department of Radiation Oncology, National Cancer Centre, Singapore
| | - Harriet Deere
- Department of Pathology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mike Green
- Department of Pathology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Nick Maisey
- Department of Medical Oncology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew R Davies
- Department of Surgery, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Gary J Cook
- School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom; The King's College London and Guy's and St Thomas' PET Centre, St Thomas' Hospital, London, United Kingdom
| | - Vicky Goh
- Department of Radiology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom; School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom.
| |
Collapse
|
6
|
Moore JL, Green M, Santaolalla A, Deere H, Evans RPT, Elshafie M, Lavery A, McManus DT, McGuigan A, Douglas R, Horne J, Walker R, Mir H, Terlizzo M, Kamarajah SK, Van Hemelrijck M, Maisey N, Sita-Lumsden A, Ngan S, Kelly M, Baker CR, Kumar S, Lagergren J, Allum WH, Gossage JA, Griffiths EA, Grabsch HI, Turkington RC, Underwood TJ, Smyth EC, Fitzgerald RC, Cunningham D, Davies AR. Pathologic Lymph Node Regression After Neoadjuvant Chemotherapy Predicts Recurrence and Survival in Esophageal Adenocarcinoma: A Multicenter Study in the United Kingdom. J Clin Oncol 2023; 41:4522-4534. [PMID: 37499209 DOI: 10.1200/jco.23.00139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE There is limited evidence regarding the prognostic effects of pathologic lymph node (LN) regression after neoadjuvant chemotherapy for esophageal adenocarcinoma, and a definition of LN response is lacking. This study aimed to evaluate how LN regression influences survival after surgery for esophageal adenocarcinoma. METHODS Multicenter cohort study of patients with esophageal adenocarcinoma treated with neoadjuvant chemotherapy followed by surgical resection at five high-volume centers in the United Kingdom. LNs retrieved at esophagectomy were examined for chemotherapy response and given a LN regression score (LNRS)-LNRS 1, complete response; 2, <10% residual tumor; 3, 10%-50% residual tumor; 4, >50% residual tumor; and 5, no response. Survival analysis was performed using Cox regression adjusting for confounders including primary tumor regression. The discriminatory ability of different LN response classifications to predict survival was evaluated using Akaike information criterion and Harrell C-index. RESULTS In total, 17,930 LNs from 763 patients were examined. LN response classified as complete LN response (LNRS 1 ≥1 LN, no residual tumor in any LN; n = 62, 8.1%), partial LN response (LNRS 1-3 ≥1 LN, residual tumor ≥1 LN; n = 155, 20.3%), poor/no LN response (LNRS 4-5; n = 303, 39.7%), or LN negative (no tumor/regression; n = 243, 31.8%) demonstrated superior discriminatory ability. Mortality was reduced in patients with complete LN response (hazard ratio [HR], 0.35; 95% CI, 0.22 to 0.56), partial LN response (HR, 0.72; 95% CI, 0.57 to 0.93) or negative LNs (HR, 0.32; 95% CI, 0.25 to 0.42) compared with those with poor/no LN response. Primary tumor regression and LN regression were discordant in 165 patients (21.9%). CONCLUSION Pathologic LN regression after neoadjuvant chemotherapy was a strong prognostic factor and provides important information beyond pathologic TNM staging and primary tumor regression grading. LN regression should be included as standard in the pathologic reporting of esophagectomy specimens.
Collapse
Affiliation(s)
- Jonathan L Moore
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Michael Green
- Department of Histopathology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Aida Santaolalla
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Harriet Deere
- Department of Histopathology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mona Elshafie
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anita Lavery
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Damian T McManus
- Department of Pathology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Andrew McGuigan
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Rosalie Douglas
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Joanne Horne
- Department of Histopathology, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Robert Walker
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Hira Mir
- Department of Histopathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Monica Terlizzo
- Department of Histopathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sivesh K Kamarajah
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mieke Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Nick Maisey
- Department of Medical Oncology, St Thomas' Hospital, London, United Kingdom
| | - Ailsa Sita-Lumsden
- Department of Medical Oncology, St Thomas' Hospital, London, United Kingdom
| | - Sarah Ngan
- Department of Medical Oncology, St Thomas' Hospital, London, United Kingdom
| | - Mark Kelly
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Cara R Baker
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Sacheen Kumar
- Department of Upper Gastrointestinal Surgery, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jesper Lagergren
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - William H Allum
- Department of Upper Gastrointestinal Surgery, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - James A Gossage
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| | - Ewen A Griffiths
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Heike I Grabsch
- Department of Pathology, GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Richard C Turkington
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Tim J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Elizabeth C Smyth
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
| | - David Cunningham
- Department of Medical Oncology, The Royal Marsden Hospital, London, United Kingdom
| | - Andrew R Davies
- Department of Upper Gastrointestinal and General Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, United Kingdom
| |
Collapse
|
7
|
Ubels S, Matthée E, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen MI, Daams F, Dekker JWT, van Det MJ, van Esser S, Griffiths EA, Haveman JW, Nieuwenhuijzen G, Siersema PD, Wijnhoven B, Hannink G, van Workum F, Rosman C, Heisterkamp J, Polat F, Schouten J, Singh P, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, Van Etten B, Poelmann F, Vuurberg N, Willem van den Berg J, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TC, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JW, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CM, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RP, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJ, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MA, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Koshy R, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Constantinoiu S, Birla R, Achim F, Rosianu CG, Hoara P, Castro RG, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Koshy R, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Ahmed HA, Elhadi A, Elnagar FA, Msherghi AA, Wills V, Campbell C, Cerdeira MP, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Barbosa JA, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZ, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler M, Schofield W, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Fernández SL, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Ben Taher FA, Ekheel M, Msherghi AA. Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue. Eur J Surg Oncol 2023; 49:974-982. [PMID: 36732207 DOI: 10.1016/j.ejso.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences. METHODS TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment. RESULTS FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4). CONCLUSION Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Eric Matthée
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | - Fatih Polat
- Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pritam Singh
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Talavera-Urquijo E, Davies AR, Wijnhoven BPL. Prevention and treatment of a positive proximal margin after gastrectomy for cardia cancer. Updates Surg 2023; 75:335-341. [PMID: 35842570 PMCID: PMC9852102 DOI: 10.1007/s13304-022-01315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/14/2022] [Indexed: 01/24/2023]
Abstract
A tumour-positive proximal margin (PPM) after extended gastrectomy for oesophagogastric junction (OGJ) adenocarcinoma is observed in approximately 2-20% of patients. Although a PPM is an unfavourable prognostic factor, the clinical relevance remains unclear as it may reflect poor tumour biology. This narrative review analyses the most relevant literature on PPM after gastrectomy for OGJ cancers. Awareness of the risk factors and possible measures that can be taken to reduce the risk of PPM are important. In patients with a PPM, surgical and non-surgical treatments are available but the effectiveness remains unclear.
Collapse
Affiliation(s)
- Eider Talavera-Urquijo
- grid.414651.30000 0000 9920 5292Department of Surgery, University Hospital of Donostia, Donostia-San Sebastián, Spain
| | - Andrew R. Davies
- grid.420545.20000 0004 0489 3985Department of Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Bas P. L. Wijnhoven
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Dunn JM, Reyhani A, Santaolalla A, Zylstra J, Gimson E, Pennington M, Baker C, Kelly M, Van Hemelrijck M, Lagergren J, Zeki SS, Gossage JA, Davies AR. Transition from esophagectomy to endoscopic therapy for early esophageal cancer. Dis Esophagus 2022; 35:6321381. [PMID: 34260693 DOI: 10.1093/dote/doab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To assess the outcomes of patients with early esophageal cancer and high-grade dysplasia comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET). METHODS Retrospective cohort study of consecutive patients with early esophageal cancer/high-grade dysplasia, treated between 2000 and 2018 at a tertiary center. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, tumor grade (G1/2 vs. G3), tumor stage, and lymphovascular invasion. Secondary outcomes included complications, hospital stay, and overall costs. RESULTS Among 269 patients, 133 underwent esophagectomy and 136 received EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85, 95% CI 0.73, 4.72) and disease-specific mortality (HR 1.10, 95% CI 0.26, 4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs. endoscopic therapy 0.74%), longer in-patient stay (median 14 vs. 0 days endoscopic therapy) and higher hospital costs(£16 360 vs. £8786 per patient). CONCLUSION This series of patients treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. It should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy.
Collapse
Affiliation(s)
- Jason M Dunn
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Arasteh Reyhani
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Aida Santaolalla
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Janine Zylstra
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Eliza Gimson
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mark Pennington
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Cara Baker
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mark Kelly
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK
| | - Mieke Van Hemelrijck
- Gastroenterology Unit,Translational Oncology & Urology Research(TOUR). King's College London, London UK
| | - Jesper Lagergren
- Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sebastian S Zeki
- Gastroenterology, Guy's and St.Thomas' Esophago-Gastric Centre, London, UK
| | - James A Gossage
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Andrew R Davies
- Esophago-Gastric Surgery, Guy's and St.Thomas' Esophago-Gastric Centre, London UK.,Gastroenterology Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| |
Collapse
|
10
|
Moore JL, Davies AR, Santaolalla A, van Hemelrijck M, Maisey N, Lagergren J, Gossage JA, Kelly M, Baker CR, Jacques A, Griffin N, Goh V, Ngan S, Lumsden A, Owczarczyk K, Qureshi A, Deere H, Green M, Chang F, Mahadeva U, Gill-Barman B, George S, Meenan J, Hill M, Waters J, Cominos M, Hynes O, Tham G, Bott RK, Dunn JM, Zeki SS. ASO Visual Abstract: Clinical Relevance of the Tumor Location-Modified Laurén Classification System of Gastric Cancer in a Western Population. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-021-11308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
11
|
Moore JL, Davies AR, Santaolalla A, Van Hemelrijck M, Maisey N, Lagergren J, Gossage JA, Kelly M, Baker CR. Clinical Relevance of the Tumor Location-Modified Laurén Classification System for Gastric Cancer in a Western Population. Ann Surg Oncol 2022; 29:3911-3920. [PMID: 35041098 PMCID: PMC9072452 DOI: 10.1245/s10434-021-11252-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
Background The Tumor Location-Modified Laurén Classification (MLC) system combines Laurén histologic subtype and anatomic tumor location. It divides gastric tumors into proximal non-diffuse (PND), distal non-diffuse (DND), and diffuse (D) types. The optimum classification of patients with Laurén mixed tumors in this system is not clear due to its grouping with both diffuse and non-diffuse types in previous studies. The clinical relevance of the MLC in a Western population has not been examined. Methods A cohort study investigated 404 patients who underwent gastrectomy for gastric adenocarcinoma between 2005 and 2020. The classification of Laurén mixed tumors was evaluated using receiver operating characteristic (ROC) curve analysis and comparison of clinicopathologic characteristics (chi-square). Survival analysis was performed using multivariable Cox regression. Results The ROC curve analysis demonstrated a slightly higher area under the curve value for predicting survival when Laurén mixed tumors were grouped with intestinal-type rather than diffuse-type tumors (0.58 vs 0.57). Survival, tumor recurrence, and resection margin positivity in mixed tumors also was more similar to intestinal type. Distal non-diffuse tumors had the best 5-year survival (DND 64.7 % vs PND 56.1 % vs diffuse 45.1 %; p = 0.006) and were least likely to have recurrence (DND 27.0 % vs PND 34.3 % vs diffuse 48.3 %; p = 0.001). Multivariable analysis demonstrated that MLC was an independent prognostic factor for survival (PND: hazard ratio [HR], 1.64; 95 % confidence interval [CI], 1.16–2.32 vs diffuse: HR, 2.20; 95 % CI, 1.56–3.09) Conclusions The MLC was an independent prognostic marker in this Western cohort of patients with gastric adenocarcinoma. The patients with PND and D tumors had worse survival than those with DND tumors.
Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-11252-y.
Collapse
Affiliation(s)
- J L Moore
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK. .,School of Cancer and Pharmaceutical Sciences, King's College, London, UK.
| | - A R Davies
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK.,School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | - A Santaolalla
- School of Cancer and Pharmaceutical Sciences, King's College, London, UK.,Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | - M Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, King's College, London, UK.,Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | - N Maisey
- Department of Medical Oncology, St. Thomas' Hospital, London, UK
| | - J Lagergren
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK.,School of Cancer and Pharmaceutical Sciences, King's College, London, UK.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J A Gossage
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK.,School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | - M Kelly
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK.,School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | - C R Baker
- Department of Upper Gastrointestinal and General Surgery, St. Thomas' Hospital, London, UK.,School of Cancer and Pharmaceutical Sciences, King's College, London, UK
| | | |
Collapse
|
12
|
Bott RK, George G, McEwen R, Zylstra J, Knight WRC, Baker CR, Kelly M, Griffin N, McAddy N, Maisey N, Van Hemelrijck M, Gossage JA, Lagergren J, Davies AR. Predicting response to neoadjuvant chemotherapy in patients with oesophageal adenocarcinoma. Acta Oncol 2021; 60:1629-1636. [PMID: 34613874 DOI: 10.1080/0284186x.2021.1986228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy is often used prior to surgical resection for oesophageal adenocarcinoma but remains ineffective in a high proportion of patients. The histological Mandard tumour regression grade is used to determine chemoresponse but is not available at the time of treatment decision-making. The aim of this cohort study was to identify factors that predict chemotherapy response prior to surgery. METHODS A prospectively collected database of patients undergoing surgical resection for oesophageal adenocarcinoma from a high-volume UK institution was used. Patients were subcategorised using pathological tumour response into 'responders' (Mandard grade 1-3) and 'non-responders' (Mandard grade 4 and 5). Multivariable logistic regression analysis was performed to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for responder status adjusting for a variety of parameters. Receiver operating characteristic (ROC) curves were calculated. RESULTS Among 315 patients included, 102 (32%) were responders and 213 (68%) non-responders. A decrease in radiological tumour volume (OR 1.92 95%CI 1.02-3.62; p = 0.05), a 'partial response' RECIST score (OR 7.16 95%CI 1.49-34.36; p = 0.01), a clinically improved dysphagia score (OR 2.79 95%CI 1.05-7.04; p = 0.04) and lymphovascular invasion (OR 0.06 95%CI 0.02-0.13; p = 0.000) influenced responder status. ROC curve analysis for responder status utilising all available parameters had an area under the curve (AUC) of 0.86. CONCLUSION This study has highlighted the potential for using pre-defined factors to identify those patients who have responded to neoadjuvant chemotherapy, prior to surgical resection, potentially facilitating a more individualised therapeutic approach.
Collapse
Affiliation(s)
- Rebecca K. Bott
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Gincy George
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King’s College London, London, UK
| | - Ricardo McEwen
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
| | - Janine Zylstra
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
| | - William R. C. Knight
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Cara R. Baker
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Mark Kelly
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Nyree Griffin
- Department of Radiology, St Thomas’ Hospital, London, UK
| | - Naami McAddy
- Department of Radiology, St Thomas’ Hospital, London, UK
| | - Nick Maisey
- Department of Medical Oncology, Guy’s Hospital London, London, UK
| | - Mieke Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King’s College London, London, UK
| | - James A. Gossage
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Jesper Lagergren
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Andrew R. Davies
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| |
Collapse
|
13
|
Foley DM, Emanuwa EJE, Knight WRC, Baker CR, Kelly M, McEwan R, Zylstra J, Davies AR, Gossage JA. Analysis of outcomes of a transoral circular stapled anastomosis following major upper gastrointestinal cancer resection. Dis Esophagus 2021; 34:6130170. [PMID: 33554244 DOI: 10.1093/dote/doab004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophageal anastomoses performed following esophagectomy and total gastrectomy are technically challenging with a significant risk of anastomotic leak. A safe, reliable, and easy anastomotic technique is required to improve patient outcomes and reduce morbidity. METHOD This paper analyses 328 consecutive patients who underwent transoral circular stapled esophageal anastomosis (ORVIL™) from a prospectively collected single-center database between December 2011 and February 2019. RESULTS Two hundred and twenty-seven esophagectomies and 101 gastrectomies were performed using OrVil™ anastomoses. The mean patient age was 63.7 years. Of 328 consecutive OrVil™-based anastomoses, there were 10 clinically significant anastomotic leaks requiring radiological or operative intervention (3.05%). Twenty-eight (8.54%) patients developed anastomotic stricture, all of which were successfully treated with endoscopic balloon dilatation (a median of 1 dilatation was required per patient). CONCLUSION The OrVil™ anastomotic technique is reliable and safe to perform. This is the largest reported series of the OrVil™ anastomotic technique to date. Leak rates and anastomotic dilations were similar to other reported series. Based on our experience, we consider the use of the OrVil™ device for reconstruction after major upper GI resection to be safe and reliable.
Collapse
Affiliation(s)
- Daniel M Foley
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - William R C Knight
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Cara R Baker
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark Kelly
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ricardo McEwan
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Janine Zylstra
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | |
Collapse
|
14
|
Pucher PH, White A, Padfield O, Davies AR, Maisey N, Qureshi A, Subesinghe M, Baker C, Gossage JA. Incidence and relevance of clinically indeterminate nonregional lymph nodes in the treatment of oesophageal cancer. Nucl Med Commun 2021; 42:1270-1276. [PMID: 34347657 DOI: 10.1097/mnm.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Metastatic involvement of nonregional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare but has important implications for prognosis and management. The management of nonregional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimeter nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up and clinical significance of nonregional clinically indeterminate FDG avid lymph nodes. METHODS A single-centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with nonregional FDG avid nodes were identified. Subsequent work-up, management and outcomes were retrieved from electronic health records. RESULTS Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine-needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false-negative lymph node sampling. CONCLUSIONS EBUS and US-FNA are effective means of sampling clinically indeterminate nonregional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued. Nonregional clinically indeterminate lymph nodes represent a diagnostic dilemma in oesophageal cancer staging. Additional investigations in the form of endobronchial ultrasound are effective at providing additional staging information, and can substantially influence patient care.
Collapse
Affiliation(s)
- Philip H Pucher
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
- Department of General Surgery, Portsmouth University Hospital NHS Trust, Portsmouth
| | - Annabelle White
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
| | - Olivia Padfield
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
| | - Andrew R Davies
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
- Division of Cancer Sciences, King's College London
| | - Nick Maisey
- Department of Oncology, Guys and St Thomas' Hospital NHS Foundation Trust
| | - Asad Qureshi
- Department of Oncology, Guys and St Thomas' Hospital NHS Foundation Trust
| | - Manil Subesinghe
- King's College London & Guy's and St. Thomas' PET Centre
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Cara Baker
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
| | - James A Gossage
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London
| |
Collapse
|
15
|
Grey CNB, Homolova L, Davies AR. Learning lessons from the community response to COVID-19 in Wales. Eur J Public Health 2021. [PMCID: PMC8574908 DOI: 10.1093/eurpub/ckab165.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background During the pandemic, community action sprang up in response to the health and social consequences of the virus. Communities were driven to support each other and those perceived as vulnerable. Community support and social capital are key for strengthening resilience, and an important contributor to population health. The aim was to explore what factors enabled community-led action in response to need amongst the most deprived areas in Wales during COVID-19. Methods Mixed-methods approach, with a strong focus on qualitative research with a systems-lens. Quantitative data was collected through a survey of 2500 adults >18 years; living, working or volunteering in Wales engaged in community action, and analysed descriptively. Outcomes were motivation, benefits, current and past activities, barriers, socio-economic characteristics [age, education, employment, postcode], digital volunteerism, resilience [RRC-ARM 12], and health and wellbeing [WEMWBS-14]. Qualitative data was collected in two communities in South Wales from 46 semi-structured interviews with recipients, volunteers, and strategic leads and analysed thematically. This explored determinants and experience of community-led action, levers and drivers, and integration with the wider system. Results Results are preliminary. They include individual-level factors underlying volunteerism and pro-social behaviour across different categories of volunteer (unstructured, informal, formal) and across national area-level deprivation indicators (WIMD), and perspectives across the system on community-led response and its role in community empowerment in supporting the vulnerable within communities. Conclusions Improved understanding of the role of community-led action as a protective factor against widening health inequalities during, and in recovery from COVID-19, was brought together to develop and coproduce a framework to empower community-led action and support sustainable integration with existing services. Key messages Understanding how community-led action sustained and be better supported and integrated into the health, third sector and social support system is important for building resilient communities. Understanding community-led action during COVID-19 will inform how this can best supported to help protect against the longer-term differences in the health, social and economic impact.
Collapse
Affiliation(s)
- CNB Grey
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - L Homolova
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - AR Davies
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| |
Collapse
|
16
|
Grey CNB, Woodfine L, Davies AR, Azam S. A mixed methods study of lived experiences of homelessness in Wales and childhood adversity. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Homelessness is a serious and complex societal and public health issue with multiple causes and solutions. Dealing with homelessness involves both supporting people at risk of homelessness and addressing personal and structural causes occurring through the life-course, including Adverse Childhood Experiences (ACEs). We examine the relationship between ACEs and homelessness in Wales, and consider priority areas for early intervention and prevention.
Methods
Data was retrospectively analysed from a 2017 cross-sectional national 2017 (n = 2452) of adults aged 16-69 years living in Wales using a stratified random probability sampling methodology. Outcome measures included number of ACEs, lifetime homelessness, and childhood resilience assets and were analysed using bivariate statistics. Pathways interviews with people experiencing homelessness (n = 27) and services (n = 16) explored experiences and views, and were analysed thematically.
Results
Homelessness affects 1 in 14 (7%) of the Welsh population in their lifetime. 87% of those with lived experience of homelessness had experienced at least one ACE compared with a Welsh average of 46%; and 50% of those with lived experience of homelessness had experienced 4+ ACEs, compared to 11% in the wider population. Compared with those with no ACEs, individuals with 4+ ACEs were 16 times more likely to report experiencing homelessness (95% CI 9.73,26.43), but Childhood Resilience Assets were protective reducing this by half (adjusted odds ratio 8.073, 95% CI 4.68,13.93). From interviews, early years/schools are critical in supporting children with ACEs, and services through the life-course need to be ACE-aware and better able to cope with impacts of ACEs.
Conclusions
A clear association is seen between ACEs and homelessness. Early intervention that prevents ACEs is needed, as well as better addressing support needs of both child and adult vulnerable populations to prevent homelessness and intervene earlier.
Key messages
In a national Welsh study, 87% of those reporting lived experience of homelessness had experienced at least one adverse childhood experience (ACE), and 50% reported four or more ACEs. Early intervention that prevents ACEs, combined with a trauma-informed approach that builds resilience in at-risk children and adults, is likely to contribute to reducing and preventing homelessness.
Collapse
Affiliation(s)
- CNB Grey
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - L Woodfine
- Policy and International Health, Public Health Wales, Cardiff, UK
| | - AR Davies
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - S Azam
- Policy and International Health, Public Health Wales, Cardiff, UK
| |
Collapse
|
17
|
Abstract
Abstract
Background
Rural, farming and fishing communities in Wales were highlighted as vulnerable to uncertainty and change from Brexit, with likely impacts to mental health and wellbeing in these groups. Policy needs to understand how to prevent challenges, protect against health impacts, and promote mental health and wellbeing in these hard-to-reach/engage groups using evidence-based solutions.
Methods
Two mixed-methods studies were undertaken in 2019-20, using identical methodologies, one in farming and one in fishing communities. For both, MEDLINE, Embase, PsycINFO, NICE, and Cochrane databases were searched for keywords associated with farmers/fishers, mental health, wellbeing, resilience, support, and suicide; for studies of any design published in English, in 2005-19. Evidence was further supported by stakeholder engagement through two world café workshops in each group (farmers n = 19, fishers n = 13). For farmers, additional face-to-face and telephone consultation took place (n = 26). Challenges, existing support, and relevance of the evidence review were examined. Engagement was recorded through researcher's field notes and analysed thematically.
Results
For farmers, 843 records were identified after duplicated removed, screened, 130 full text records examined, and 14 interventions included. For fishers, 415 records identified, 135 full text examined, and 7 interventions included. Evidence-based programmes supporting farmers were centred on health promotion, mental health literacy, and cross-agency partnership development; and for fishers, support was centred solely on health promotion. Qualitative engagement uncovered challenges faced in Wales, barriers to seeking support, and assets available to each group.
Conclusions
The evidence from the review and engagement was brought together to create action frameworks for supporting both farmers and fishers in Wales, centred on prevention, protection, and promotion of mental health and wellbeing.
Key messages
Farming and fishing are contributors to Wales’ rural economy and cultural identity. A strong evidence-base of how to support mental health of these groups is vital to help them cope with change. Action for supporting both farmers and fishers in Wales should be centred on prevention, protection, and promotion of mental health and wellbeing.
Collapse
Affiliation(s)
- AR Davies
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - CNB Grey
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - L Homolova
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| |
Collapse
|
18
|
Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, Ponsford J, Seppelt I, Reilly P, Wiegers E, Wolfe R. Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial. J Neurotrauma 2021; 37:810-816. [PMID: 32027212 PMCID: PMC7071071 DOI: 10.1089/neu.2019.6869] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.
Collapse
Affiliation(s)
- D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Andrew R Davies
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Monash-Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Peter Reilly
- Neurosurgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eveline Wiegers
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | |
Collapse
|
19
|
Aboul-Enein MS, Knight W, Wulaningsih W, Foley DM, Dellaportas D, Zylstra J, Baker CR, Kelly M, Smyth E, Lagergren J, Maisey N, Allum WH, Gossage JA, Cunningham D, Davies AR. The role of surgery after prolonged primary chemotherapy for advanced oesophageal adenocarcinoma. J Surg Oncol 2021; 124:1296-1305. [PMID: 34403501 DOI: 10.1002/jso.26648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy. METHODS This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables. CONCLUSION Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery.
Collapse
Affiliation(s)
- Mohamed S Aboul-Enein
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,General Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - William Knight
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - Wahyu Wulaningsih
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - Daniel M Foley
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | | | - Janine Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,General Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Cara R Baker
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mark Kelly
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Jesper Lagergren
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Nick Maisey
- Department of Oncology, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | | | - James A Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,General Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David Cunningham
- Department of Oncology, Royal Marsden Hospital, London, UK.,Biomedical Research Centre, Institute of Cancer Research, London, UK
| | - Andrew R Davies
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
20
|
Pucher PH, Wijnhoven BPL, Underwood TJ, Reynolds JV, Davies AR. Thinking through the multimodal treatment of localized oesophageal cancer: the point of view of the surgeon. Curr Opin Oncol 2021; 33:353-361. [PMID: 33966001 DOI: 10.1097/cco.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW This review examines current developments and controversies in the multimodal management of oesophageal cancer, with an emphasis on surgical dilemmas and outcomes from the surgeon's perspective. RECENT FINDINGS Despite the advancement of oncological neoadjuvant treatments, there is still no consensus on what regimen is superior. The majority of patients may still fail to respond to neoadjuvant therapy and suffer potential harm without any survival advantage as a result. In patients who do not respond, adjuvant therapy is still often recommended after surgery despite any evidence for its benefit. We examine the implications of different regimens and treatment approaches for both squamous cell cancer and adenocarcinoma of the oesophagus. SUMMARY The efficacy of neoadjuvant treatment is highly variable and likely relates to variability of tumour biology. Ongoing work to identify responders, or optimize treatment on an individual patient, should increase the efficacy of multimodal therapy and improve patient outcomes.
Collapse
Affiliation(s)
- Philip H Pucher
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London
- Department of Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Timothy J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - John V Reynolds
- Department of Surgery, National Oesophageal and Gastric Center, St. James's Hospital and Trinity College, Dublin, Ireland
| | - Andrew R Davies
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London
- King's College London, London, UK
| |
Collapse
|
21
|
Ridley EJ, Davies AR, Bernard S, McArthur C, Murray L, Paul E, Trapani A, Cooper DJ. Measured energy expenditure in mildly hypothermic critically ill patients with traumatic brain injury: A sub-study of a randomized controlled trial. Clin Nutr 2021; 40:3875-3882. [PMID: 34130035 DOI: 10.1016/j.clnu.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7. METHODS A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)). RESULTS Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p < 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p < 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days. CONCLUSION In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients. TRIAL REGISTRY NUMBER POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia; Nutrition Department, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Stephen Bernard
- Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Lynne Murray
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Antony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia; Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia
| | | |
Collapse
|
22
|
Bott RK, Beckmann K, Zylstra J, Wilkinson MJ, Knight WRC, Baker CR, Kelly M, Maisey N, Waters J, Van Hemelrijck M, Smyth EC, Allum WH, Lagergren J, Gossage JA, Cunningham D, Davies AR. Adjuvant therapy following neoadjuvant chemotherapy and surgery for oesophageal adenocarcinoma in patients with clear resection margins. Acta Oncol 2021; 60:672-680. [PMID: 33586602 DOI: 10.1080/0284186x.2021.1885057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of adjuvant therapy in patients with oesophagogastric adenocarcinoma treated by neoadjuvant chemotherapy (NAC) and surgery is contentious. In UK practice, surgical resection margin status is often used to classify patients into receiving adjuvant treatment. This study aimed to assess any survival benefit of adjuvant therapy in patients with clear resection margins. METHODS This was a retrospective collaborative cohort study combining two prospectively collected UK institutional databases of patients with oesophageal adenocarcinoma. Multivariable Cox regression and propensity matched analyses were used to compare overall and recurrence-free survival according to the adjuvant treatment. RESULTS Of 374 patients with clear resection margins, 221 patients (59%) had no adjuvant treatment, 137 patients (37%) had adjuvant chemotherapy and 16 patients (4%) had adjuvant chemoradiotherapy. For patients who had received NAC (290, 76%), when adjuvant chemotherapy was compared to no adjuvant treatment, hazard ratios (HRs) favoured adjuvant chemotherapy but did not reach independent significance (overall survival [OS] HR 0.65 95% confidence interval [CI] 0.40-1.06; p .0.087). Responders to NAC (Mandard 1-3) were seemingly more likely to demonstrate a survival benefit from adjuvant chemotherapy (HR 0.42 95% CI 0.15-1.11; p .1.081). CONCLUSIONS Although no independent survival benefit was observed, the point estimates favoured adjuvant treatment, predominantly in patients with chemo-responsive tumours.
Collapse
Affiliation(s)
- Rebecca K. Bott
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Kerri Beckmann
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King’s College London, London, UK
- University of South Australia Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Janine Zylstra
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
| | - Michelle J. Wilkinson
- Department of Upper Gastrointestinal Surgery, The Royal Marsden Hospital, London, UK
| | - William R. C. Knight
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Cara R. Baker
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Mark Kelly
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Nick Maisey
- Department of Medical Oncology, Guy’s Hospital, London, UK
| | - Justin Waters
- Department of Medical Oncology, Maidstone Hospital, Kent, UK
| | - Mieke Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King’s College London, London, UK
| | | | - William H. Allum
- Department of Upper Gastrointestinal Surgery, The Royal Marsden Hospital, London, UK
| | - Jesper Lagergren
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - James A. Gossage
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - David Cunningham
- Department of Medical Oncology, The Royal Marsden Hospital, London, UK
| | - Andrew R. Davies
- Department of Upper Gastrointestinal and General Surgery, St Thomas’ Hospital, London, UK
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| |
Collapse
|
23
|
Chapple LAS, Summers MJ, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Finnis ME, Hurford S, Lange K, Little L, O'Connor SN, Peake SL, Ridley EJ, Young PJ, Williams PJ, Deane AM. Use of a High-Protein Enteral Nutrition Formula to Increase Protein Delivery to Critically Ill Patients: A Randomized, Blinded, Parallel-Group, Feasibility Trial. JPEN J Parenter Enteral Nutr 2020; 45:699-709. [PMID: 33296079 DOI: 10.1002/jpen.2059] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. METHODS We conducted a prospective, randomized, blinded, parallel-group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). RESULTS The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high-protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38-0.69] g/kg/d protein), with no difference in energy delivery (difference, -26 [95% CI, -190 to 137] kcal/kg/d). There were no between-group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90-day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, -1.3% [95% CI, -17.7% to 15.0%]). CONCLUSION Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline-recommended levels with doses similar to usual care during critical illness.
Collapse
Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Matthew J Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia.,The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, Frankston Hospital, Frankston, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Patricia J Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
| | -
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
24
|
Gray BJ, Grey C, Hookway A, Homolova L, Davies AR. Differences in the impact of precarious employment on health across population subgroups: a scoping review. Perspect Public Health 2020; 141:37-49. [PMID: 33269663 PMCID: PMC7770217 DOI: 10.1177/1757913920971333] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aim: Precarious employment is known to be detrimental to health, and some population subgroups (young individuals, migrant workers, and females) are at higher risk of precarious employment. However, it is not known if the risk to poor health outcomes is consistent across population subgroups. This scoping review explores differential impacts of precarious employment on health. Methods: Relevant studies published between 2009 and February 2019 were identified across PubMed, OVID Medline, PsycINFO, and Scopus. Articles were included if (1) they presented original data, (2) examined precarious employment within one of the subpopulations of interest, and (3) examined health outcomes. Results: Searches yielded 279 unique results, of which 14 met the eligibility criteria. Of the included studies, 12 studies examined differences between gender, 3 examined the health impacts on young individuals, and 3 examined the health of migrant workers. Mental health was explored in nine studies, general health in four studies, and mortality in two studies. Conclusion: Mental health was generally poorer in both male and female employees as a result of precarious employment, and males were also at higher risk of mortality. There was limited evidence that met our inclusion criteria, examining the health impacts on young individuals or migrant workers.
Collapse
Affiliation(s)
- B J Gray
- Knowledge Directorate, Research and Evaluation Division, Public Health Wales, Number 2 Capital Quarter, Tyndall Street, Cardiff CF10 4BZ, UK
| | - Cnb Grey
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - A Hookway
- Observatory Evidence Service, Public Health Wales, Cardiff, UK
| | - L Homolova
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| | - A R Davies
- Research and Evaluation Division, Public Health Wales, Cardiff, UK
| |
Collapse
|
25
|
Reyhani A, Zylstra J, Davies AR, Gossage JA. Laparoscopic-assisted left thoracoabdominal esophagectomy (LLTA): an innovative approach for locally advanced tumors of the gastroesophageal junction. Dis Esophagus 2020; 33:5780066. [PMID: 32129450 DOI: 10.1093/dote/doaa014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/02/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE To report a novel approach for locally advanced tumors located at the gastroesophageal junction (GEJ) using a laparoscopic abdominal phase and open left thoracotomy with the patient in a single right lateral decubitus position. BACKGROUND The standard open left thoracoabdominal approach offers excellent exposure and access to the GEJ and lower esophagus. It also involves a single position for the procedure, shortening the operation time. The disadvantages are a large incision, division of the costochondral junction, and a low-level thoracotomy. The laparoscopic-assisted left thoracoabdominal esophagectomy (LLTA) is performed with the patient in the same right lateral decubitus position, but initially rolled away from the operator at 45° allowing laparoscopic gastric mobilization and lymphadenectomy. The patient is then tilted back to the lateral position for the thoracic phase. An anterolateral left thoracotomy is performed through the higher fifth intercostal space allowing a high intrathoracic anastomosis, just below the aortic arch. No disruption of the costochondral junction is made. METHODS Consecutive patients selectively treated for locally advanced GEJ tumors with an LLTA approach between 2013 and 2019 were analyzed and compared to national standards (NOGCA). RESULTS This series of 74 consecutive patients had a mean age of 63 years. The median operation time was 235 minutes. The median inpatient stay was 10 days (NOGCA 9 [11-17]). The tumors were predominantly adenocarcinoma (95%) and located at the GEJ (92%). The majority were locally advanced T3 or T4 tumors. Postoperative morbidity was low, Clavien-Dindo (C-D) 0 in 52.7% patients, C-D1 (1.4%), C-D2 (31.1%), C-D3a (5.4%), C-D4a (9.5%), and C-D5 (1.4%). The median number of total lymph nodes (LN) excised was 28 (NOGCA >15); LN % yield ≥18 was 90% (NOGCA 82.5%). Positive nodes were located at the lesser-curve (40%), paraesophageal (32.4%), and subcarinal regions (2.7%). Positive circumferential resection margins (<1 mm) were present in 28.4% of resected specimens (NOGCA 25.1%). This is reflective of the high proportion T3/T4 tumors selected for this approach. Hospital and 30-day mortality was 1.4% (NOGCA 2.7%). Recurrence after LLTA was 25.7% (local 5.4%, systemic 17.6%, mixed 2.7%) at a median of 311 days (62-1,158). CONCLUSION This series demonstrates a novel, safe, and reproducible approach for locally advanced cancer of the GEJ. It offers a better exposure of the hiatus than the right-sided approach and avoids division of the costochondral junction and low thoracotomy seen with the open left thoracoabdominal approach.
Collapse
Affiliation(s)
- A Reyhani
- Guy's and St Thomas' Esophago-Gastric Research Group, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - J Zylstra
- Guy's and St Thomas' Esophago-Gastric Research Group, London, UK
| | - A R Davies
- Guy's and St Thomas' Esophago-Gastric Research Group, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - J A Gossage
- Guy's and St Thomas' Esophago-Gastric Research Group, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| |
Collapse
|
26
|
Bott RK, Beckmann K, Zylstra J, Wilkinson MJ, Knight WRC, Baker CR, Kelly M, Maisey N, Qureshi A, Sevitt T, Van Hemelrijck M, Smyth EC, Allum WH, Lagergren J, Gossage JA, Cunningham D, Davies AR. Adjuvant therapy following oesophagectomy for adenocarcinoma in patients with a positive resection margin. Br J Surg 2020; 107:1801-1810. [PMID: 32990343 DOI: 10.1002/bjs.11864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/18/2020] [Accepted: 06/08/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND The role of adjuvant therapy in patients with oesophagogastric adenocarcinoma treated by neoadjuvant chemotherapy is contentious. In UK practice, surgical resection margin status is often used to classify patients for receiving adjuvant treatment. The aim of this study was to assess the survival benefit of adjuvant therapy in patients with positive (R1) resection margins. METHODS Two prospectively collected UK institutional databases were combined to identify eligible patients. Adjusted Cox regression analyses were used to compare overall and recurrence-free survival according to adjuvant treatment. Recurrence patterns were assessed as a secondary outcome. Propensity score-matched analysis was also performed. RESULTS Of 616 patients included in the combined database, 242 patients who had an R1 resection were included in the study. Of these, 112 patients (46·3 per cent) received adjuvant chemoradiotherapy, 46 (19·0 per cent) were treated with adjuvant chemotherapy and 84 (34·7 per cent) had no adjuvant treatment. In adjusted analysis, adjuvant chemoradiotherapy improved recurrence-free survival (hazard ratio (HR) 0·59, 95 per cent c.i. 0·38 to 0·94; P = 0·026), with a benefit in terms of both local (HR 0·48, 0·24 to 0·99; P = 0·047) and systemic (HR 0·56, 0·33 to 0·94; P = 0·027) recurrence. In analyses stratified by tumour response to neoadjuvant chemotherapy, non-responders (Mandard tumour regression grade 4-5) treated with adjuvant chemoradiotherapy had an overall survival benefit (HR 0·61, 0·38 to 0·97; P = 0·037). In propensity score-matched analysis, an overall survival benefit (HR 0·62, 0·39 to 0·98; P = 0·042) and recurrence-free survival benefit (HR 0·51, 0·30 to 0·87; P = 0·004) were observed for adjuvant chemoradiotherapy versus no adjuvant treatment. CONCLUSION Adjuvant therapy may improve overall survival and recurrence-free survival after margin-positive resection. This pattern seems most pronounced with adjuvant chemoradiotherapy in non-responders to neoadjuvant chemotherapy.
Collapse
Affiliation(s)
- R K Bott
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital.,School of Cancer and Pharmaceutical Sciences
| | - K Beckmann
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK.,University of South Australia Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - J Zylstra
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital
| | - M J Wilkinson
- Departments of Upper Gastrointestinal Surgery, London, UK
| | - W R C Knight
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital
| | - C R Baker
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital.,School of Cancer and Pharmaceutical Sciences
| | - M Kelly
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital.,School of Cancer and Pharmaceutical Sciences
| | - N Maisey
- Departments of Medical Oncology, London, UK
| | - A Qureshi
- Clinical Oncology, Guy's Hospital, London, UK
| | - T Sevitt
- Department of Medical Oncology, Maidstone Hospital, Maidstone, UK
| | - M Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK
| | - E C Smyth
- Medical Oncology, Royal Marsden Hospital, London, UK
| | - W H Allum
- Departments of Upper Gastrointestinal Surgery, London, UK
| | - J Lagergren
- School of Cancer and Pharmaceutical Sciences.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J A Gossage
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital.,School of Cancer and Pharmaceutical Sciences
| | - D Cunningham
- Medical Oncology, Royal Marsden Hospital, London, UK
| | - A R Davies
- Department of Upper Gastrointestinal and General Surgery, St Thomas' Hospital.,School of Cancer and Pharmaceutical Sciences
| | | |
Collapse
|
27
|
Davies AR, Homolova L, Grey CNB, Bellis MA. Health and mass unemployment events-developing a framework for preparedness and response. J Public Health (Oxf) 2020; 41:665-673. [PMID: 30289466 PMCID: PMC6923517 DOI: 10.1093/pubmed/fdy174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mass unemployment events are not uncommon yet the impact on health is not well recognised. There is a need for a preparedness and response framework, as exists for other events that threaten population health. METHODS Framework informed by a narrative review of the impact of mass unemployment on health (studies published in English from 1990 to 2016), and qualitative data from 23 semi-structured interviews with individuals connected to historical national and international events, addressing gaps in published literature on lessons learnt from past responses. RESULTS Economic and employment shock triggered by mass unemployment events have a detrimental impact on workers, families and communities. We present a public health informed response framework which includes (i) identify areas at risk, (ii) develop an early warning system, (iii) mobilise multi-sector action including health and community, (iv) provision of support across employment, finance and health (v) proportionate to need, (vi) extend support to family members and (vii) communities and (viii) evaluate and learn. CONCLUSION Mass unemployment events have an adverse impact on the health, financial and social circumstances of workers, families, and communities. This is the first framework for action to mitigate and address the detrimental impact of mass unemployment events on population health.
Collapse
Affiliation(s)
- A R Davies
- Policy, Research and International Development Directorate, Public Health Wales, Cardiff, UK
| | - L Homolova
- Policy, Research and International Development Directorate, Public Health Wales, Cardiff, UK
| | - C N B Grey
- Policy, Research and International Development Directorate, Public Health Wales, Cardiff, UK
| | - M A Bellis
- Policy, Research and International Development Directorate, Public Health Wales, Cardiff, UK
| |
Collapse
|
28
|
Bosch KD, Chicklore S, Cook GJ, Davies AR, Kelly M, Gossage JA, Baker CR. Staging FDG PET-CT changes management in patients with gastric adenocarcinoma who are eligible for radical treatment. Eur J Nucl Med Mol Imaging 2020; 47:759-767. [PMID: 31377821 PMCID: PMC7075833 DOI: 10.1007/s00259-019-04429-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/09/2019] [Indexed: 12/12/2022]
Abstract
AIM 18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) is valuable in the management of patients with oesophageal cancer, but a role in gastric cancer staging is debated. Our aim was to review the role of FDG PET-CT in a large gastric cancer cohort in a tertiary UK centre. METHODS We retrospectively reviewed data from 330 patients presenting with gastric adenocarcinoma between March 2014 and December 2016 of whom 105 underwent pre-treatment staging FDG PET-CT scans. FDG PET-CT scans were graded qualitatively and quantitatively (SUVmax) and compared with staging diagnostic CT and operative pathology results (n = 30) in those undergoing resection. RESULTS Of the 105 patients (74 M, median age 73 years) 86% of primary tumours were metabolically active (uptake greater than normal stomach) on FDG PET-CT [41/44 (93%) of the intestinal histological subtype (SUVmax 14.1 ± 1.3) compared to 36/46 (78%) of non-intestinal types (SUVmax 9.0 ± 0.9), p = 0.005]. FDG PET-CT upstaged nodal or metastastic staging of 20 patients (19%; 13 intestinal, 6 non-intestinal, 1 not reported), with 17 showing distant metastases not evident on other imaging. On histological analysis, available in 30 patients, FDG PET-CT showed low sensitivity (40%) but higher specificity (73%) for nodal involvement. CONCLUSION FDG PET-CT provides new information in a clinically useful proportion of patients, which leads to changes in treatment strategy, most frequently by detecting previously unidentified metastases, particularly in those with intestinal-type tumours.
Collapse
Affiliation(s)
- Karen D Bosch
- Department of Upper GI Surgery, Guy's & St Thomas' Hospital, London, SE1 7EH, UK.
| | - Sugama Chicklore
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
- King's College London and Guy's & St Thomas' PET Centre, St Thomas' Hospital, London, SE1 7EH, UK
| | - Gary J Cook
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
- King's College London and Guy's & St Thomas' PET Centre, St Thomas' Hospital, London, SE1 7EH, UK
| | - Andrew R Davies
- Department of Upper GI Surgery, Guy's & St Thomas' Hospital, London, SE1 7EH, UK
| | - Mark Kelly
- Department of Upper GI Surgery, Guy's & St Thomas' Hospital, London, SE1 7EH, UK
| | - James A Gossage
- Department of Upper GI Surgery, Guy's & St Thomas' Hospital, London, SE1 7EH, UK
| | - Cara R Baker
- Department of Upper GI Surgery, Guy's & St Thomas' Hospital, London, SE1 7EH, UK
| |
Collapse
|
29
|
Deane AM, Little L, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Horowitz M, Hurford S, Lange K, Litton E, Mackle D, O'Connor S, Parker J, Peake SL, Presneill JJ, Ridley EJ, Singh V, van Haren F, Williams P, Young P, Iwashyna TJ. Outcomes Six Months after Delivering 100% or 70% of Enteral Calorie Requirements during Critical Illness (TARGET). A Randomized Controlled Trial. Am J Respir Crit Care Med 2020; 201:814-822. [PMID: 31904995 DOI: 10.1164/rccm.201909-1810oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown.Objectives: Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later.Methods: We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition.Measurements and Main Results: Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work (n = 818). There was no observed difference in disability (n = 1,208) or participation in key life activities (n = 705).Conclusions: The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.
Collapse
Affiliation(s)
- Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | | | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | | | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Jeffrey J Presneill
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vanessa Singh
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Frank van Haren
- Medical School, Australian National University, Canberra, Australia; and
| | | | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
30
|
Dellaportas D, Zylstra J, Gossage J, Baker C, Kelly M, Hemelrijck MV, Griffin N, Lagergren J, Davies AR. The Prognostic Role of Pre-operative Positron Emission Tomography-Computed Tomography and Endoscopic Ultrasound Parameters in Oesophageal Adenocarcinoma. Chirurgia (Bucur) 2019; 114:443-450. [PMID: 31511130 DOI: 10.21614/chirurgia.114.4.443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 11/23/2022]
Abstract
Background: To evaluate the prognostic role of Positron Emission Tomography/Computed Tomography (PET/CT) and Endoscopic Ultrasound (EUS) performed before neoadjuvant chemotherapy (NAC) and surgery for oesophageal adenocarcinoma (OAC) patients, focusing on lymph node (LN) assessment. Methods: OAC patients treated in a single tertiary center during January 2008 until December 2014 were retrospectively studied. All patients had PET/CT and EUS before NAC and oesophagectomy. PET-FDG-avid local LNs and maximum standardized uptake value (SUVmax) of the primary tumour, EUS positive LNs and EUS tumour length were recorded. Univariate, multivariate and survival analyses were performed. Results: Following exclusions 151consecutive patients met the inclusion criteria, (median age 62 years). PET/CT and EUS sensitivity for local LNs metastasis was 39.2% and 88.6%, with specificities of 83.33% and 19.15% respectively. No overall survival (OS) difference was found between patients with PET/CT FDG-avid LNs and those with negative LNs (p=0.347). SUVmax uptake was divided into high and low (median cut-off value: 10) with no significant difference in OS between groups (p=0.141). EUS tumour length was not prognostic (OS, p=0.455). Conclusions: Initial LN staging in OA is inaccurate. Although PET/CT and EUS assessments may be complimentary, none independently predicted survival.
Collapse
|
31
|
Zylstra J, Davies AR, Pate J, Tham G, Maisey N, Baker CR, Kelly M, Gossage J, Browning M, Whyte G. Feasibility Of Exercise Prehabilitation During Neo-adjuvant Chemotherapy In Oesophago-gastric Cancer Surgery. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000561780.97589.3d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
32
|
Smyth EC, Nyamundanda G, Cunningham D, Fontana E, Ragulan C, Tan IB, Lin SJ, Wotherspoon A, Nankivell M, Fassan M, Lampis A, Hahne JC, Davies AR, Lagergren J, Gossage JA, Maisey N, Green M, Zylstra JL, Allum WH, Langley RE, Tan P, Valeri N, Sadanandam A. A seven-Gene Signature assay improves prognostic risk stratification of perioperative chemotherapy treated gastroesophageal cancer patients from the MAGIC trial. Ann Oncol 2018; 29:2356-2362. [PMID: 30481267 PMCID: PMC6311954 DOI: 10.1093/annonc/mdy407] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Following neoadjuvant chemotherapy for operable gastroesophageal cancer, lymph node metastasis is the only validated prognostic variable; however, within lymph node groups there is still heterogeneity with risk of relapse. We hypothesized that gene profiles from neoadjuvant chemotherapy treated resection specimens from gastroesophageal cancer patients can be used to define prognostic risk groups to identify patients at risk for relapse. Patients and methods The Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial (n = 202 with high quality RNA) samples treated with perioperative chemotherapy were profiled for a custom gastric cancer gene panel using the NanoString platform. Genes associated with overall survival (OS) were identified using penalized and standard Cox regression, followed by generation of risk scores and development of a NanoString biomarker assay to stratify patients into risk groups associated with OS. An independent dataset served as a validation cohort. Results Regression and clustering analysis of MAGIC patients defined a seven-Gene Signature and two risk groups with different OS [hazard ratio (HR) 5.1; P < 0.0001]. The median OS of high- and low-risk groups were 10.2 [95% confidence interval (CI) of 6.5 and 13.2 months] and 80.9 months (CI: 43.0 months and not assessable), respectively. Risk groups were independently prognostic of lymph node metastasis by multivariate analysis (HR 3.6 in node positive group, P = 0.02; HR 3.6 in high-risk group, P = 0.0002), and not prognostic in surgery only patients (n = 118; log rank P = 0.2). A validation cohort independently confirmed these findings. Conclusions These results suggest that gene-based risk groups can independently predict prognosis in gastroesophageal cancer patients treated with neoadjuvant chemotherapy. This signature and associated assay may help risk stratify these patients for post-surgery chemotherapy in future perioperative chemotherapy-based clinical trials.
Collapse
Affiliation(s)
| | - G Nyamundanda
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - D Cunningham
- Royal Marsden Hospital, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - E Fontana
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - C Ragulan
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - I B Tan
- Medical Oncology, National Cancer Centre Singapore, Singapore
| | - S J Lin
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research, Victoria, Australia; Division of Research, Peter MacCallum Cancer Centre, University of Melbourne, Victoria, Australia
| | | | - M Nankivell
- Clinical Trials Unit, Medical Research Council, University College London, London, UK
| | - M Fassan
- Department of Pathology, University of Padua, Padua, Italy
| | - A Lampis
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - J C Hahne
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | | | - J Lagergren
- Guys & St Thomas' Hospital, London, UK; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - N Maisey
- Guys & St Thomas' Hospital, London, UK
| | - M Green
- Guys & St Thomas' Hospital, London, UK
| | - J L Zylstra
- Department of Pathology, University of Padua, Padua, Italy
| | | | - R E Langley
- Clinical Trials Unit, Medical Research Council, University College London, London, UK
| | - P Tan
- Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore
| | - N Valeri
- Royal Marsden Hospital, London, UK; Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - A Sadanandam
- Division of Molecular Pathology, Institute of Cancer Research, London, UK; Centre for Molecular Pathology, Royal Marsden Hospital, London, UK.
| |
Collapse
|
33
|
Zylstra J, Boshier P, Whyte GP, Low DE, Davies AR. Peri-operative patient optimization for oesophageal cancer surgery - From prehabilitation to enhanced recovery. Best Pract Res Clin Gastroenterol 2018; 36-37:61-73. [PMID: 30551858 DOI: 10.1016/j.bpg.2018.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/19/2018] [Indexed: 02/08/2023]
Affiliation(s)
- J Zylstra
- Department of Gastrointestinal Medicine and Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Sport and Exercise Science, Faculty of Science, Liverpool John Moore's University, Liverpool, UK
| | - P Boshier
- Virginia Mason Medical Centre, Seattle, USA
| | - G P Whyte
- School of Sport and Exercise Science, Faculty of Science, Liverpool John Moore's University, Liverpool, UK; Research Institute for Sport & Exercise Science, Liverpool John Moore's University, UK
| | - D E Low
- Virginia Mason Medical Centre, Seattle, USA
| | - A R Davies
- Department of Gastrointestinal Medicine and Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK; Division of Cancer Studies, King's College London, UK.
| |
Collapse
|
34
|
Davies AR, Myoteri D, Zylstra J, Baker CR, Wulaningsih W, Van Hemelrijck M, Maisey N, Allum WH, Smyth E, Gossage JA, Lagergren J, Cunningham D, Green M. Lymph node regression and survival following neoadjuvant chemotherapy in oesophageal adenocarcinoma. Br J Surg 2018; 105:1639-1649. [PMID: 30047556 DOI: 10.1002/bjs.10900] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/12/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim was to define the pathological response in lymph nodes following neoadjuvant chemotherapy for oesophageal adenocarcinoma and to quantify any associated survival benefit. METHODS Lymph nodes retrieved at oesophagectomy were examined retrospectively by two pathologists for evidence of a response to chemotherapy. Patients were classified as lymph node-negative (either negative nodes with no evidence of previous tumour involvement or negative with evidence of complete regression) or positive (allocated a lymph node regression score based on the proportion of fibrosis to residual tumour). Lymph node responders (score 1, complete response; 2, less than 10 per cent remaining tumour; 3, 10-50 per cent remaining tumour) and non-responders (score 4, more than 50 per cent viable tumour; 5, no response) were compared in survival analyses using Kaplan-Meier and Cox regression analysis. RESULTS Among 377 patients, 256 had neoadjuvant chemotherapy. Overall, 68 of 256 patients (26·6 per cent) had a lymph node response and 115 (44·9 per cent) did not. The remaining 73 patients (28·5 per cent) had negative lymph nodes with no evidence of regression. Some patients had a lymph node response in the absence of a response in the primary tumour (27 of 99, 27 per cent). Lymph node responders had a significant survival benefit (P < 0·001), even when stratified by patients with or without a response in the primary tumour. On multivariable analysis, lymph node responders had decreased overall (hazard ratio 0·53, 95 per cent c.i. 0·36 to 0·78) and disease-specific (HR 0·42, 0·27 to 0·66) mortality, and experienced reduced local and systemic recurrence. CONCLUSION Lymph node regression is a strong prognostic factor and may be more important than response in the primary tumour.
Collapse
Affiliation(s)
- A R Davies
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Myoteri
- Department of Cellular Pathology, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C R Baker
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
| | - W Wulaningsih
- Translational Oncology and Urology Research, School of Cancer Sciences, King's College London, London, UK
| | - M Van Hemelrijck
- Translational Oncology and Urology Research, School of Cancer Sciences, King's College London, London, UK
| | - N Maisey
- Department of Oncology, Guy's Cancer Centre, Guy's Hospital, London, UK
| | - W H Allum
- Department of Oncology, Royal Marsden Hospital, London, UK
| | - E Smyth
- Department of Oncology, Royal Marsden Hospital, London, UK
| | - J A Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Lagergren
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Cunningham
- Department of Oncology, Royal Marsden Hospital, London, UK
- Institute of Cancer Research, London, UK
| | - M Green
- Department of Cellular Pathology, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| |
Collapse
|
35
|
Ridley EJ, Parke RL, Davies AR, Bailey M, Hodgson C, Deane AM, McGuinness S, Cooper DJ. What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults. JPEN J Parenter Enteral Nutr 2018; 43:88-95. [PMID: 29924393 DOI: 10.1002/jpen.1196] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/01/2018] [Accepted: 04/12/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults. METHODS This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]). RESULTS Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement. CONCLUSIONS Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Nutrition Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Rachael L Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, New Zealand
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, New Zealand
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
36
|
Ridley EJ, Peake SL, Jarvis M, Deane AM, Lange K, Davies AR, Chapman M, Heyland D. Nutrition Therapy in Australia and New Zealand Intensive Care Units: An International Comparison Study. JPEN J Parenter Enteral Nutr 2018; 42:1349-1357. [DOI: 10.1002/jpen.1163] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/16/2018] [Indexed: 01/05/2023]
Affiliation(s)
- Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre; Department of Epidemiology and Preventive Medicine; Monash University; Victoria Australia
- Nutrition Department; Alfred Health; Melbourne Australia
| | - Sandra L. Peake
- Australian and New Zealand Intensive Care Research Centre; Department of Epidemiology and Preventive Medicine; Monash University; Victoria Australia
- Department of Intensive Care; The Queen Elizabeth Hospital; Woodville South Australia Australia
- School of Medicine; University of Adelaide; South Australia Australia
| | - Matthew Jarvis
- School of Medicine; University of Adelaide; South Australia Australia
- Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Adam M. Deane
- Australian and New Zealand Intensive Care Research Centre; Department of Epidemiology and Preventive Medicine; Monash University; Victoria Australia
- Intensive Care Unit; The Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - Kylie Lange
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Discipline of Medicine; University of Adelaide; South Australia Australia
| | - Andrew R. Davies
- Australian and New Zealand Intensive Care Research Centre; Department of Epidemiology and Preventive Medicine; Monash University; Victoria Australia
| | - Marianne Chapman
- School of Medicine; University of Adelaide; South Australia Australia
- Royal Adelaide Hospital; Adelaide South Australia Australia
- Centre for Research Excellence in Translating Nutritional Science to Good Health; Discipline of Medicine; University of Adelaide; South Australia Australia
| | - Daren Heyland
- Department of Critical Care Medicine; Kingston General Hospital; Queen's University; Ontario Canada
| |
Collapse
|
37
|
Knight WRC, Zylstra J, Wulaningsih W, Van Hemelrijck M, Landau D, Maisey N, Gaya A, Baker CR, Gossage JA, Largergren J, Davies AR. Impact of incremental circumferential resection margin distance on overall survival and recurrence in oesophageal adenocarcinoma. BJS Open 2018; 2:229-237. [PMID: 30079392 PMCID: PMC6069345 DOI: 10.1002/bjs5.65] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/02/2018] [Indexed: 01/04/2023] Open
Abstract
Background Previous analyses of the oesophageal circumferential resection margin (CRM) have focused on the prognostic validity of two different definitions of a positive CRM, that of the College of American Pathologists (tumour at margin) and that of the Royal College of Pathologists (tumour within 1 mm). This study aimed to analyse the validity of these definitions and explore the risk of recurrence and survival with incremental tumour distances from the CRM. Methods This cohort study included patients who underwent resection for adenocarcinoma of the oesophagus between 2000 and 2014. Kaplan-Meier and Cox regression analyses were performed to determine the hazard ratio (HR) with 95 per cent confidence intervals for recurrence and mortality in CRM increments: tumour at the cut margin, extending to within 0·1-0·9, 1·0-1·9, 2·0-4·9 mm, and 5·0 mm or more from the margin. Results A total of 444 patients were included in the study. Kaplan-Meier and unadjusted analyses showed a significant incremental improvement in overall survival (P < 0·001) and recurrence (P for trend < 0·001) rates with increasing distance from the CRM. Tumour distance of 2·0 mm or more remained a significant predictor of survival on multivariable analysis (HR for risk of death 0·66, 95 per cent c.i. 0·44 to 1·00). Multivariable analysis of overall survival demonstrated a significant difference between a positive and negative CRM with the Royal College of Pathologists' definition (HR 1·37, 1·01 to 1·85), but not with the College of American Pathologists' definition (HR 1·22, 0·90 to 1·65). Conclusion This study demonstrated an incremental improvement in survival and recurrence rates with increasing tumour distance from the CRM.
Collapse
Affiliation(s)
- W R C Knight
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK
| | - J Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - W Wulaningsih
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
| | - M Van Hemelrijck
- Cancer Epidemiology and Population Health Associated Research Group, King's College London, London, UK
| | - D Landau
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - N Maisey
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - A Gaya
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - C R Baker
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J A Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Largergren
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A R Davies
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
38
|
Knight WRC, Zylstra J, Van Hemelrijck M, Griffin N, Jacques AET, Maisey N, Baker CR, Gossage JA, Largergren J, Davies AR. Patterns of recurrence in oesophageal cancer following oesophagectomy in the era of neoadjuvant chemotherapy. BJS Open 2018; 1:182-190. [PMID: 29951621 PMCID: PMC5989962 DOI: 10.1002/bjs5.30] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/30/2017] [Indexed: 12/15/2022] Open
Abstract
Background Tumour recurrence following oesophagectomy for oesophageal cancer is common despite neoadjuvant treatment. Understanding patterns of recurrence and risk factors associated with locoregional and systemic recurrence might influence future treatment strategies. Methods This was a cohort study involving patients undergoing resection for adenocarcinoma or squamous cell carcinoma of the oesophagus between 2000 and 2014. Clinicopathological factors associated with locoregional and systemic recurrence were analysed using multivariable logistic regression to determine odds ratios (ORs) and 95 per cent confidence intervals. Results Some 698 patients were identified. Lymphovascular invasion (OR 2·09, 95 per cent c.i. 1·18 to 3·71) and preoperative stenting (OR 3·70, 1·34 to 10·23) were independent risk factors for isolated locoregional recurrence. Pathological nodal disease in patients with pT1–2 (pN1: OR 2·72, 1·35 to 5·48; pN2–3: OR 5·00, 2·35 to 10·66) or pT3–4 (pN1: OR 3·03, 1·51 to 6·07; pN2–3: OR 5·75, 3·15 to 10·49) disease predisposed to systemic recurrence. Poor or no response to chemotherapy was also an independent risk factor for isolated systemic recurrence (OR 1·85, 1·05 to 3·26). A positive resection margin (R1 resection) was not associated with a significantly increased risk of isolated locoregional recurrence (OR 1·37, 0·81 to 2·33). Conclusion These findings confirm that oesophageal adenocarcinoma is frequently a systemic disease. Understanding the key predictors of local and systemic recurrence may facilitate the tailoring of oncological therapies to the individual patient.
Collapse
Affiliation(s)
- W R C Knight
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK.,Division of Cancer Studies Division of Cancer Studies King's College London London UK
| | - J Zylstra
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK
| | - M Van Hemelrijck
- Translational Oncology and Urology Research (TOUR) Division of Cancer Studies King's College London London UK
| | - N Griffin
- Department of Radiology Guy's and St Thomas' Hospital London UK
| | - A E T Jacques
- Department of Radiology Guy's and St Thomas' Hospital London UK
| | - N Maisey
- Department of Oncology Guy's and St Thomas' Hospital London UK
| | - C R Baker
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK
| | - J A Gossage
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK.,Division of Cancer Studies Division of Cancer Studies King's College London London UK.,Gastrointestinal Research Unit, Department of Molecular Medicine and Surgery Karolinska Institute, Stockholm, Sweden, on behalf of the Guy's and St Thomas' Oesophago-Gastric Research Group
| | - J Largergren
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK.,Division of Cancer Studies Division of Cancer Studies King's College London London UK.,Gastrointestinal Research Unit, Department of Molecular Medicine and Surgery Karolinska Institute, Stockholm, Sweden, on behalf of the Guy's and St Thomas' Oesophago-Gastric Research Group
| | - A R Davies
- Department of Surgery Guy's and St Thomas' Oesophago-Gastric Centre London UK.,Division of Cancer Studies Division of Cancer Studies King's College London London UK.,Gastrointestinal Research Unit, Department of Molecular Medicine and Surgery Karolinska Institute, Stockholm, Sweden, on behalf of the Guy's and St Thomas' Oesophago-Gastric Research Group
| |
Collapse
|
39
|
Davies AR, Zylstra J, Baker CR, Gossage JA, Dellaportas D, Lagergren J, Findlay JM, Puccetti F, El Lakis M, Drummond RJ, Dutta S, Mera A, Van Hemelrijck M, Forshaw MJ, Maynard ND, Allum WH, Low D, Mason RC. A comparison of the left thoracoabdominal and Ivor-Lewis esophagectomy. Dis Esophagus 2018; 31:4566196. [PMID: 29087474 DOI: 10.1093/dote/dox129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/05/2017] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.
Collapse
Affiliation(s)
- A R Davies
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Zylstra
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C R Baker
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J A Gossage
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - D Dellaportas
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre
| | - J Lagergren
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J M Findlay
- Department of Upper Gastrointestinal Surgery, Oxford Esophago-Gastric Centre, Oxford University Hospitals.,NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford
| | - F Puccetti
- Department of Surgery, Royal Marsden Hospital, London
| | - M El Lakis
- Department of Thoracic Surgery, Virginia Mason Medical Centre, Seattle, Washington, USA
| | - R J Drummond
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - S Dutta
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - A Mera
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London
| | - M Van Hemelrijck
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London
| | - M J Forshaw
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - N D Maynard
- Department of Upper Gastrointestinal Surgery, Oxford Esophago-Gastric Centre, Oxford University Hospitals
| | - W H Allum
- Department of Surgery, Royal Marsden Hospital, London
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Centre, Seattle, Washington, USA
| | - R C Mason
- Department of Surgery, Guy's & St Thomas' Esophago-Gastric Centre.,Division of Cancer Studies, King's College London.,Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
40
|
Kauppila JH, Johar A, Gossage JA, Davies AR, Zylstra J, Lagergren J, Lagergren P. Health-related quality of life after open transhiatal and transthoracic oesophagectomy for cancer. Br J Surg 2018; 105:230-236. [DOI: 10.1002/bjs.10745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 01/07/2023]
Abstract
Abstract
Background
Transhiatal and transthoracic oesophagectomy in patients with oesophageal cancer have similar survival rates. Whether these approaches differ in health-related quality of life (HRQoL) is uncertain and was examined in this study.
Methods
Patients undergoing transhiatal or transthoracic surgery for lower-third oesophageal or gastro-oesophageal junctional cancer between 2011 and 2015 were selected from an institutional database. HRQoL outcomes were measured at 6 and 12 months after surgery using validated written questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25). Linear mixed models provided mean score differences (MSDs) with 95 per cent confidence intervals, adjusted for preoperative HRQoL, age, physical status (ASA fitness grade), tumour location, tumour stage, neoadjuvant therapy, adjuvant therapy and postoperative complications. MSD values of 10 or more were regarded as clinically relevant.
Results
Some 146 patients underwent transhiatal (86, 58·9 per cent) or transthoracic (60, 41·1 per cent) oesophagectomy. The HRQoL questionnaires were returned by 111 patients at 6 months and 74 at 12 months. At 6 months, transthoracic oesophagectomy was associated with worse role function (MSD –12, 95 per cent c.i. –23 to 0; P = 0·046). At 12 months, patients in the transthoracic group had more nausea and vomiting (MSD 11, 0 to 22; P = 0·045), dyspnoea (MSD 13, 1 to 25; P = 0·029) and constipation (MSD 20, 7 to 33; P = 0·003) than those in the transhiatal group.
Conclusion
Transhiatal oesophagectomy seems to offer better HRQoL than transthoracic oesophagectomy 6 and 12 months after surgery.
Collapse
Affiliation(s)
- J H Kauppila
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Cancer and Translational Medicine Research Unit, Medical Research Centre, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - A Johar
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - J A Gossage
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - A R Davies
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Zylstra
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - P Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
41
|
Ridley EJ, Davies AR, Parke R, Bailey M, McArthur C, Gillanders L, Cooper DJ, McGuinness S. Supplemental parenteral nutrition versus usual care in critically ill adults: a pilot randomized controlled study. Crit Care 2018; 22:12. [PMID: 29361959 PMCID: PMC5781264 DOI: 10.1186/s13054-018-1939-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/02/2018] [Indexed: 12/29/2022]
Abstract
Background In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48–72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery. Methods This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted. Results There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m2. Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups. Conclusions This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups. Trial registration Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016) Electronic supplementary material The online version of this article (10.1186/s13054-018-1939-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia. .,Nutrition Department, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Rachael Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Lyn Gillanders
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Nutrition and Dietetics, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, VIC, 3004, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | | |
Collapse
|
42
|
Ridley EJ, Davies AR, Hodgson CL, Deane A, Bailey M, Cooper DJ. Delivery of full predicted energy from nutrition and the effect on mortality in critically ill adults: A systematic review and meta-analysis of randomised controlled trials. Clin Nutr 2017; 37:1913-1925. [PMID: 29061391 DOI: 10.1016/j.clnu.2017.09.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/02/2017] [Accepted: 09/29/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The amount of energy required to improve clinical outcomes in critically ill adults is unknown. OBJECTIVE The aim of this systematic review and meta-analysis was to evaluate the impact of near target energy delivery to critically ill adults on mortality and other clinically relevant outcomes. DESIGN Following PRISMA guidelines, MEDLINE, EMBASE, CINHAL and the Cochrane Library were searched for randomised controlled trials evaluating nutrition interventions in adult critical care populations. Included studies compared delivery of ≥80% of predicted energy requirements (near target) from enteral and/or parenteral nutrition to <80% (standard care) and reported mortality. The quality of individual studies was assessed using the Cochrane 'Risk of Bias' tool, and the overall body of evidence using the GRADE approach. Fixed or random effect meta-analyses were used pending the presence of heterogeneity (I2 > 50%) when 3 or more studies reported the same outcome. Outcomes are presented as risk ratio (RR), 95% confidence interval (CI). RESULTS Ten trials with 3155 participants were included. Mortality was unaffected by the intervention (RR 1.02, 95% CI 0.81, 1.27, p = 0.89, I2 = 25%). Evaluation of studies of higher quality and low risk of bias did not alter the mortality inference (3 trials, 352 participants, RR 0.83, 95% CI 0.49, 1.40, p = 0.19, I2 = 39%). The quality of evidence across outcomes was very low. CONCLUSIONS The delivery of near target energy when compared to standard care in adult critically ill patients was not associated with an effect on mortality. Because the quality of the evidence across outcomes was very low there is considerable uncertainty surrounding this estimate. This has implications for clinical utility of the evidence within the included reviews.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia; Nutrition Department, Alfred Health, Commercial Road, Melbourne, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - Adam Deane
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - D Jamie Cooper
- Department of Intensive Care Medicine, The Alfred, Commercial Road, Melbourne 3004, Australia.
| |
Collapse
|
43
|
Andreyev HJN, Muls AC, Shaw C, Jackson RR, Gee C, Vyoral S, Davies AR. Guide to managing persistent upper gastrointestinal symptoms during and after treatment for cancer. Frontline Gastroenterol 2017; 8:295-323. [PMID: 29067157 PMCID: PMC5641845 DOI: 10.1136/flgastro-2016-100714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/30/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Guidance: the practical management of the gastrointestinal symptoms of pelvic radiation disease was published in 2014 for a multidisciplinary audience. Following this, a companion guide to managing upper gastrointestinal (GI) consequences was developed. AIMS The development and peer review of an algorithm which could be accessible to all types of clinicians working with patients experiencing upper GI symptoms following cancer treatment. METHODS Experts who manage patients with upper GI symptoms were asked to review the guide, rating each section for agreement with the recommended measures and suggesting amendments if necessary. Specific comments were discussed and incorporated as appropriate, and this process was repeated for a second round of review. RESULTS 21 gastroenterologists, 11 upper GI surgeons, 9 specialist dietitians, 8 clinical nurse specialists, 5 clinical oncologists, 3 medical oncologists and 4 others participated in the review. Consensus (defined prospectively as 60% or more panellists selecting 'strongly agree' or 'agree') was reached for all of the original 31 sections in the guide, with a median of 90%. 85% of panellists agreed that the guide was acceptable for publication or acceptable with minor revisions. 56 of the original 61 panellists participated in round 2. 93% agreed it was acceptable for publication after the first revision. Further minor amendments were made in response to round 2. CONCLUSIONS Feedback from the panel of experts developed the guide with improvement of occasional algorithmic steps, a more user-friendly layout, clearer time frames for referral to other teams and addition of procedures to the appendix.
Collapse
Affiliation(s)
- H Jervoise N Andreyev
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Ann C Muls
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Clare Shaw
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Richard R Jackson
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Caroline Gee
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Susan Vyoral
- The GI and Nutrition Team, The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | |
Collapse
|
44
|
Qadan M, Davies AR, Polk HC, Allum WH, Brennan MF. Cancer care in the developed world: A comparison of surgical oncology training programs. Am J Surg 2017; 215:1-7. [PMID: 28619263 DOI: 10.1016/j.amjsurg.2017.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/01/2017] [Accepted: 05/12/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Andrew R Davies
- Department of Surgery, Guy's and St. Thomas NHS Foundation Trust, London, England, UK
| | - Hiram C Polk
- Department of Surgery, University of Louisville, Louisville, KY, USA; Kentucky Department of Public Health, Louisville, KY, USA
| | - William H Allum
- Department of Surgery, Royal Marsden Hospital, London, England, UK
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
45
|
Fisher RA, Griffiths EA, Evison F, Mason RC, Zylstra J, Davies AR, Alderson D, Gossage JA. A national audit of colonic interposition for esophageal replacement. Dis Esophagus 2017; 30:1-10. [PMID: 28375436 DOI: 10.1093/dote/dow003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/12/2016] [Indexed: 12/11/2022]
Abstract
Esophageal replacement by colonic interposition is an uncommon procedure. This study sought to identify the frequency of this operation in England, identify techniques and associated problems, and also assess health-related quality of life (HR QOL) from the two largest centers performing this procedure. Hospital Episode Statistics were used to identify patients and centers undertaking colon interposition between March 2001 and March 2015. An online survey of UK consultants discussed methods and experience. HR QOL was assessed using the Short Form 36(SF-36v2) with additional gastrointestinal questions. Hospital Episode Statistics identified 328 interpositions (22 in pediatric hospitals). The two highest volume units did 42 and 45 operations, respectively. Thirty-four surgeons (79% response rate) replied to the survey. Fifty-two percent preferred to use the left colon with 81% preferring a substernal placement. The HR QOL survey was performed on 24 patients with a median of 3 years after surgery (ranging from 9 months to 10 years) from the two largest centers and a 56% response rate. Five patients had physical QOL scores above population average and 10 had mental scores above population average. All patients had early satiety, 20 described dysphagia, and 18 regularly took antireflux medication. There was an estimated mean loss of 13.1% body weight (10.6 kg) postoperatively and three patients still relied on a feeding tube for nutrition after an average of 3 years. Colon interposition results in an acceptable long-term QOL. Few centers regularly perform this operation, and centralizing to high-volume centers may lead to better outcomes.
Collapse
Affiliation(s)
- R A Fisher
- GKT School of Medical Education, King's College London, London, UK.,Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - E A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - F Evison
- Department of Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R C Mason
- GKT School of Medical Education, King's College London, London, UK.,Department of Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Zylstra
- GKT School of Medical Education, King's College London, London, UK.,Department of Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A R Davies
- GKT School of Medical Education, King's College London, London, UK.,Department of Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - D Alderson
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J A Gossage
- GKT School of Medical Education, King's College London, London, UK.,Department of Upper Gastrointestinal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
46
|
Rice TW, Chen LQ, Hofstetter WL, Smithers BM, Rusch VW, Wijnhoven BPL, Chen KL, Davies AR, D'Journo XB, Kesler KA, Luketich JD, Ferguson MK, Räsänen JV, van Hillegersberg R, Fang W, Durand L, Cecconello I, Allum WH, Cerfolio RJ, Pera M, Griffin SM, Burger R, Liu JF, Allen MS, Law S, Watson TJ, Darling GE, Scott WJ, Duranceau A, Denlinger CE, Schipper PH, Lerut TEMR, Orringer MB, Ishwaran H, Apperson-Hansen C, DiPaola LM, Semple ME, Blackstone EH. Worldwide Esophageal Cancer Collaboration: pathologic staging data. Dis Esophagus 2016; 29:724-733. [PMID: 27731547 PMCID: PMC5731491 DOI: 10.1111/dote.12520] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/03/2016] [Accepted: 06/04/2016] [Indexed: 02/05/2023]
Abstract
We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning.
Collapse
Affiliation(s)
- T W Rice
- Cleveland Clinic, Cleveland, Ohio, USA.
| | - L-Q Chen
- West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - W L Hofstetter
- University of Texas MD Anderson Hospital, Houston, Texas, USA
| | - B M Smithers
- University of Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - V W Rusch
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | - K L Chen
- Beijing Cancer Hospital, Beijing, China
| | - A R Davies
- Guy's & St Thomas' Hospitals, London, England
| | | | - K A Kesler
- Indiana University Medical Center, Indianapolis, Indiana, USA
| | - J D Luketich
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - M K Ferguson
- Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - J V Räsänen
- Helsinki University Hospital, Helsinki, Finland
| | | | - W Fang
- Shanghai Chest Hospital, Shanghai, China
| | - L Durand
- Hospital de Clinicas, University of Buenos Aires, Buenos Aires, Argentina
| | - I Cecconello
- University of São Paulo School of Medicine, São Paulo, Brazil
| | - W H Allum
- Royal Marsden NHS Foundation Trust, London, UK
| | - R J Cerfolio
- Section of Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - M Pera
- Hospital Universitario del Mar, Barcelona, Spain
| | - S M Griffin
- University of Newcastle upon Tyne, Newcastle, United Kingdom
| | - R Burger
- University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - J-F Liu
- Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - M S Allen
- Mayo Clinic, Rochester, Minnesota, USA
| | - S Law
- University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China
| | - T J Watson
- University of Rochester, Rochester, New York, USA
| | - G E Darling
- Toronto General Hospital, Toronto, Ontario, Canada
| | - W J Scott
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - A Duranceau
- University of Montreal, Montreal, Quebec, Canada
| | - C E Denlinger
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - P H Schipper
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - M B Orringer
- University of Michigan, Ann Arbor, Michigan, USA
| | - H Ishwaran
- University of Miami, Miami, Florida, USA
| | | | | | | | | |
Collapse
|
47
|
Tullie LGC, Sohn HM, Zylstra J, Mattsson F, Griffin N, Sharma N, Porté F, Ramage L, Cook GJ, Gossage JA, Mason RC, Lagergren J, Davies AR. A Role for Tumor Volume Assessment in Resectable Esophageal Cancer. Ann Surg Oncol 2016; 23:3063-70. [PMID: 27112584 DOI: 10.1245/s10434-016-5228-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Esophageal cancer has a poor prognosis, and many patients undergoing surgery have a low chance of cure. Imaging studies suggest that tumor volume is prognostic. The study aimed to evaluate pathological tumor volume (PTV) as a prognostic variable in esophageal cancer. METHODS This single-center cohort study included 283 patients who underwent esophageal cancer resections between 2000 and 2012. PTVs were obtained from pathological measurements using a validated volume formula. The prognostic value of PTV was analyzed using multivariable regression models, adjusting for age, tumor grade, tumor (T) stage, nodal stage, lymphovascular invasion, resection margin, resection type, and chemotherapy response, which provided hazard ratios (HRs) with 95 % confidence intervals (CIs). Primary outcomes were time to death and time to recurrence. Secondary outcomes were margin involvement and lymph node positivity. Correlation analysis was performed between imaging and PTVs. RESULTS On unadjusted analysis, increasing PTV was associated with worse overall mortality (HR 2.30, 95 % CI 1.41-3.73) and disease recurrence (HR 1.87, 95 % CI 1.14-3.07). Adjusted analysis demonstrated worse overall mortality with increasing PTV but reached significance in only one subgroup (HR 1.70, 95 % CI 1.09-2.38). PTV was an independent predictor of margin involvement (OR 2.28, 95 % CI 1.02-5.13) and lymph node-positive status (OR 2.77, 95 % CI 1.23-6.28). Correlation analyses demonstrated significant positive correlation between computed tomography (CT) software and formula tumor volumes (r = 0.927, p < 0.0001), CT and positron emission tomography tumor volumes (r = 0.547, p < 0.0001), and CT and PTVs (r = 0.310, p < 0.001). CONCLUSIONS Tumor volume may predict survival, margin status, and lymph node positivity after surgery for esophageal cancer.
Collapse
Affiliation(s)
- Lucinda G C Tullie
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK.
| | - Hyon-Mok Sohn
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
| | - Janine Zylstra
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
| | - Fredrik Mattsson
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Nyree Griffin
- Department of Radiology, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
| | - Naveen Sharma
- Department of Radiology, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
| | - Francois Porté
- Department of Radiology, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
| | - Lisa Ramage
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
| | - Gary J Cook
- Department of Radiology, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
| | - James A Gossage
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Robert C Mason
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Andrew R Davies
- Department of Upper Gastrointestinal Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Oesophago-Gastric Centre, London, UK
- Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
48
|
Reid DB, Chapple LS, O'Connor SN, Bellomo R, Buhr H, Chapman MJ, Davies AR, Eastwood GM, Ferrie S, Lange K, McIntyre J, Needham DM, Peake SL, Rai S, Ridley EJ, Rodgers H, Deane AM. The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission. Anaesth Intensive Care 2016; 44:406-12. [PMID: 27246942 DOI: 10.1177/0310057x1604400309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.
Collapse
Affiliation(s)
- D B Reid
- Intensive Care Registrar, Royal Adelaide Hospital, Adelaide, South Australia
| | - L S Chapple
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland
| | - S N O'Connor
- Research Manager, Intensive Care Unit, Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia
| | - R Bellomo
- Intensive Care Consultant, Austin Hospital, Melbourne, Victoria
| | - H Buhr
- Research Manager, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - M J Chapman
- Director of Research, Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - A R Davies
- Research Fellow, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - G M Eastwood
- Research Manager, Department of Intensive Care, Austin Hospital, Melbourne, Victoria
| | - S Ferrie
- Critical Care Dietitian, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - K Lange
- Biostatistician, Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - J McIntyre
- Research Coordinator, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - D M Needham
- Medical Director, Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, USA
| | - S L Peake
- Senior Intensive Care Clinician, Discipline of Acute Care Medicine, University of Adelaide, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - S Rai
- Intensive Care Specialist, The Canberra Hospital, Canberra, Australian Capital Territory
| | - E J Ridley
- Nutrition Program Manager, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - H Rodgers
- Research Coordinator, The Canberra Hospital, Canberra, Australian Capital Territory
| | - A M Deane
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| |
Collapse
|
49
|
Peñuelas O, Muriel A, Frutos-Vivar F, Fan E, Raymondos K, Rios F, Nin N, Thille AW, González M, Villagomez AJ, Davies AR, Du B, Maggiore SM, Matamis D, Abroug F, Moreno RP, Kuiper MA, Anzueto A, Ferguson ND, Esteban A. Prediction and Outcome of Intensive Care Unit-Acquired Paresis. J Intensive Care Med 2016; 33:16-28. [PMID: 27080128 DOI: 10.1177/0885066616643529] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intensive care unit-acquired paresis (ICUAP) is associated with poor outcomes. Our objective was to evaluate predictors for ICUAP and the short-term outcomes associated with this condition. METHODS A secondary analysis of a prospective study including 4157 mechanically ventilated adults in 494 intensive care units from 39 countries. After sedative interruption, patients were screened for ICUAP daily, which was defined as the presence of symmetric and flaccid quadriparesis associated with decreased or absent deep tendon reflexes. A multinomial logistic regression was used to create a predictive model for ICUAP. Propensity score matching was used to estimate the relationship between ICUAP and short-term outcomes (ie, weaning failure and intensive care unit [ICU] mortality). RESULTS Overall, 114 (3%) patients had ICUAP. Variables associated with ICUAP were duration of mechanical ventilation (relative risk ratio [RRR] per day, 1.10; 95% confidence interval [CI] 1.08-1.12), steroid therapy (RRR 1.8; 95% CI, 1.2-2.8), insulin therapy (RRR 1.8; 95% CI 1.2-2.7), sepsis (RRR 1.9; 95% CI: 1.2 to 2.9), acute renal failure (RRR 2.2; 95% CI 1.5-3.3), and hematological failure (RRR 1.9; 95% CI: 1.2-2.9). Coefficients were used to generate a weighted scoring system to predict ICUAP. ICUAP was significantly associated with both weaning failure (paired rate difference of 22.1%; 95% CI 9.8-31.6%) and ICU mortality (paired rate difference 10.5%; 95% CI 0.1-24.0%). CONCLUSIONS Intensive care unit-acquired paresis is relatively uncommon but is significantly associated with weaning failure and ICU mortality. We constructed a weighted scoring system, with good discrimination, to predict ICUAP in mechanically ventilated patients at the time of awakening.
Collapse
Affiliation(s)
- Oscar Peñuelas
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Alfonso Muriel
- 2 Unidad de Bioestadística Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS) & Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Frutos-Vivar
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Eddy Fan
- 3 Interdepartmental Division of Critical Care Medicine, and Departments of Medicine & Physiology, University of Toronto, Canada
| | | | - Fernando Rios
- 5 Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Nicolás Nin
- 6 Hospital Universitario de Montevideo, Uruguay
| | | | - Marco González
- 8 Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Asisclo J Villagomez
- 9 Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), México DF, México
| | - Andrew R Davies
- 10 Alfred Hospital & Monash University, Melbourne, Australia
| | - Bin Du
- 11 Peking Union Medical College Hospital, Beijing, Popular Republic of China
| | - Salvatore M Maggiore
- 12 Policlinico "Agostino Gemelli", Università Cattolica Del Sacro Cuore, Roma, Italy
| | | | - Fekri Abroug
- 14 Hospital Fattouma Bourguina, Monastir, Tunisia
| | - Rui P Moreno
- 15 Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | | | - Antonio Anzueto
- 17 South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Niall D Ferguson
- 3 Interdepartmental Division of Critical Care Medicine, and Departments of Medicine & Physiology, University of Toronto, Canada
| | - Andrés Esteban
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| |
Collapse
|
50
|
Ridley EJ, Davies AR, Parke R, Bailey M, McArthur C, Gillanders L, Cooper DJ, McGuinness S. Supplemental parenteral nutrition in critically ill patients: a study protocol for a phase II randomised controlled trial. Trials 2015; 16:587. [PMID: 26703919 PMCID: PMC4690293 DOI: 10.1186/s13063-015-1118-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/14/2015] [Indexed: 01/23/2023] Open
Abstract
Background Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed “supplemental parenteral nutrition”), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill. Methods/design This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first). Discussion This trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial. Trial registration NCT01847534 (First registered 5 February 2013, last updated 14 October 2015) Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1118-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia. .,Nutrition Department, Alfred Health, Commercial Road, Melbourne, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - Rachael Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia. .,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. .,Medical Research Institute of New Zealand, Wellington, New Zealand. .,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.
| | - Lyn Gillanders
- Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand. .,The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. .,Nutrition and Dietetics, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.
| | - David J Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia. .,Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia.
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Commercial Road, Melbourne, 3004, Australia. .,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. .,Medical Research Institute of New Zealand, Wellington, New Zealand.
| | | |
Collapse
|