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den Boer RB, Jones KI, Ash S, van Boxel GI, Gillies RS, O'Donnell T, Ruurda JP, Sgromo B, Silva MA, Maynard ND. Impact on postoperative complications of changes in skeletal muscle mass during neoadjuvant chemotherapy for gastro-oesophageal cancer. BJS Open 2020; 4:847-854. [PMID: 32841538 PMCID: PMC7528528 DOI: 10.1002/bjs5.50331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/08/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Risk assessment is relevant to predict postoperative outcomes in patients with gastro-oesophageal cancer. This cohort study aimed to assess body composition changes during neoadjuvant chemotherapy and investigate their association with postoperative complications. METHODS Consecutive patients with gastro-oesophageal cancer undergoing neoadjuvant chemotherapy and surgery with curative intent between 2016 and 2019 were identified from a specific database and included in the study. CT images before and after neoadjuvant chemotherapy were used to assess the skeletal muscle index, sarcopenia, and subcutaneous and visceral fat index. RESULTS In a cohort of 199 patients, the mean skeletal muscle index decreased during neoadjuvant therapy (from 51·187 to 49·19 cm2 /m2 ; P < 0·001) and the rate of sarcopenia increased (from 42·2 to 54·3 per cent; P < 0·001). A skeletal muscle index decrease greater than 5 per cent was not associated with an increased risk of total postoperative complications (odds ratio 0·91, 95 per cent c.i. 0·52 to 1·59; P = 0·736) or severe complications (odds ratio 0·66, 0·29 to 1·53; P = 0·329). CONCLUSION Skeletal muscle index decreased during neoadjuvant therapy but was not associated with postoperative complications.
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Affiliation(s)
- R B den Boer
- Departments of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - K I Jones
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - S Ash
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | | | - R S Gillies
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - T O'Donnell
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - J P Ruurda
- Departments of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - B Sgromo
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - M A Silva
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - N D Maynard
- Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
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2
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MacGregor TP, Carter R, Gillies RS, Findlay JM, Kartsonaki C, Castro-Giner F, Sahgal N, Wang LM, Chetty R, Maynard ND, Cazier JB, Buffa F, McHugh PJ, Tomlinson I, Middleton MR, Sharma RA. Translational study identifies XPF and MUS81 as predictive biomarkers for oxaliplatin-based peri-operative chemotherapy in patients with esophageal adenocarcinoma. Sci Rep 2018; 8:7265. [PMID: 29739952 PMCID: PMC5940885 DOI: 10.1038/s41598-018-24232-2] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
Oxaliplatin-based chemotherapy is used to treat patients with esophageal adenocarcinoma (EAC), but no biomarkers are currently available for patient selection. We performed a prospective, clinical trial to identify potential biomarkers associated with clinical outcomes. Tumor tissue was obtained from 38 patients with resectable EAC before and after 2 cycles of oxaliplatin-fluorouracil chemotherapy. Pre-treatment mRNA expression of 280 DNA repair (DNAR) genes was tested for association with histopathological regression at surgery, disease-free survival (DFS) and overall survival (OS). High expression of 13 DNA damage repair genes was associated with DFS less than one year (P < 0.05); expression of 11 DNAR genes were associated with worse OS (P < 0.05). From clinical associations with outcomes, two genes, ERCC1 and EME1, were identified as candidate biomarkers. In cell lines in vitro, we showed the mechanism of action related to repair of oxaliplatin-induced DNA damage by depletion and knockout of protein binding partners of the candidate biomarkers, XPF and MUS81 respectively. In clinical samples from the clinical trial, pre-treatment XPF protein levels were associated with pathological response, and MUS81 protein was associated with 1-year DFS. XPF and MUS81 merit further validation in prospective clinical trials as biomarkers that may predict clinical response of EAC to oxaliplatin-based chemotherapy.
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Affiliation(s)
- T P MacGregor
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R Carter
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R S Gillies
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
| | - J M Findlay
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - C Kartsonaki
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit (MRC PHRU) at the University of Oxford, Oxford, UK
| | - F Castro-Giner
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - N Sahgal
- Ludwig Institute for Cancer Research, University of Oxford, Nuffield Department of Medicine, Oxford, UK
| | - L M Wang
- NIHR Oxford Biomedical Research Centre/Department of Cellular Pathology/Radcliffe Department of Medicine, Oxford University Hospitals and University of Oxford, Oxford, UK
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - R Chetty
- Laboratory Medicine Programme, University Health Network, Toronto, Canada
| | - N D Maynard
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
| | - J B Cazier
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - F Buffa
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - P J McHugh
- Department of Oncology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - I Tomlinson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - M R Middleton
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R A Sharma
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK.
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
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3
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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.
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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
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4
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Findlay JM, Bradley KM, Wang LM, Franklin JM, Teoh EJ, Gleeson FV, Maynard ND, Gillies RS, Middleton MR. Metabolic nodal response as a prognostic marker after neoadjuvant therapy for oesophageal cancer. Br J Surg 2017; 104:947. [PMID: 28518409 DOI: 10.1002/bjs.10611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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5
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Findlay JM, Bradley KM, Wang LM, Franklin JM, Teoh EJ, Gleeson FV, Maynard ND, Gillies RS, Middleton MR. Metabolic nodal response as a prognostic marker after neoadjuvant therapy for oesophageal cancer. Br J Surg 2017; 104:408-417. [PMID: 28093719 DOI: 10.1002/bjs.10435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 03/29/2016] [Revised: 07/01/2016] [Accepted: 10/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ability to predict recurrence and survival after neoadjuvant chemotherapy (NAC) and surgery for oesophageal cancer remains elusive. This study evaluated the role of [18 F]fluorodeoxyglucose (FDG) PET-CT in assessing tumour and nodal response as a prognostic marker. METHODS This was a single-centre UK cohort study. From 2006 to 2014, patients with oesophageal cancer staged with PET-CT before NAC, and restaged by CT or PET-CT before resection, were included. Pathological tumour response was evaluated using Mandard regression grades. Metabolic tumour and nodal responses (mTR and mNR respectively) were quantified using absolute and threshold reductions. RESULTS Among 294 included patients, mTR and mNR independently predicted prognosis before surgery. After surgery, mNR (but not mTR), pathological tumour response, resection margin status and pathological node category predicted prognosis. Patients with FDG-avid nodal disease after NAC were at high risk of recurrence/death at 1 and 2 years (43 and 71 per cent respectively; P = 0·030 and P = 0·025 versus patients without avid nodes), and had a worse prognosis than patients with non-avid nodal metastases: hazard ratio 4·19 (95 per cent c.i. 1·87 to 9·40) and 2·11 (1·12 to 3·97) respectively versus patients without nodal metastases. Considering mTR and mNR response separately improved prognostication. CONCLUSION mNR is a novel prognostic factor, independent of conventional N status. Primary and nodal tumours may respond discordantly and patients with FDG-avid nodes after NAC have a poor prognosis.
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Affiliation(s)
- J M Findlay
- Oxford OesophagoGastric Centre, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - K M Bradley
- Department of Nuclear Medicine, Churchill Hospital, Oxford, UK
| | - L M Wang
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- Department of Pathology, John Radcliffe Hospital, Oxford, UK
| | - J M Franklin
- Department of Nuclear Medicine, Churchill Hospital, Oxford, UK
| | - E J Teoh
- Department of Nuclear Medicine, Churchill Hospital, Oxford, UK
| | - F V Gleeson
- Department of Nuclear Medicine, Churchill Hospital, Oxford, UK
| | | | | | - M R Middleton
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
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6
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Findlay JM, Tilson RC, Harikrishnan A, Sgromo B, Marshall REK, Maynard ND, Gillies RS, Middleton MR. Attempted validation of the NUn score and inflammatory markers as predictors of esophageal anastomotic leak and major complications. Dis Esophagus 2015; 28:626-33. [PMID: 24894195 DOI: 10.1111/dote.12244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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] [Indexed: 12/11/2022]
Abstract
The ability to predict complications following esophagectomy/extended total gastrectomy would be of great clinical value. A recent study demonstrated significant correlations between anastomotic leak (AL) and numerical values of C-reactive protein (CRP), white cell count (WCC) and albumin measured on postoperative day (POD) 4. A predictive model comprising all three (NUn score >10) was found to be highly sensitive and discriminant in predicting AL and complications. We attempted a retrospective validation in our center. Data were collected on all resections performed during a 5-year period (April 2008-2013) using prospectively maintained databases. Our biochemistry laboratory uses a maximum CRP value (156 mg/L), unlike that of the original study; otherwise all variables and outcome measures were comparable. Analysis was performed for all patients with complete blood results on POD4. Three hundred twenty-six patients underwent resection, of which 248 had POD4 bloods. There were 21 AL overall (6.44%); 16 among those with complete POD4 blood results (6.45%). There were 8 (2.45%) in-hospital deaths; 7 (2.82%) in those with POD4 results. No parameters were associated with AL or complication severity on univariate analysis. WCC was associated with AL in multivariate binary logistic regression with albumin and CRP (OR 1.23 [95% CI 1.03-1.47]; P = 0.021). When a binary variable of CRP ≥ 156 mg/L was used rather than an absolute value, no factors were significant. Mean NUn was 8.30 for AL, compared with 8.40 for non-AL (P = 0.710 independent t-test). NUn > 10 predicted 0 of 16 leaks (sensitivity 0.00%, specificity 94.4%, receiver operator curve [ROC] area under the curve [AUC] 0.485; P = 0.843). NUn > 7.65 was 93% sensitive and 21.6% specific. ROC for WCC alone was comparable with NUn (AUC 0.641 [0.504-0.779]; P = 0.059; WCC > 6.89 93.8% sensitive, 20.7% specific; WCC > 15 6.3% sensitive and 97% specific). There were no associations between any parameters and other complications. In a comparable cohort with the original study, we demonstrated a similar multivariate association between WCC alone on POD4 and subsequent demonstration of AL, but not albumin or CRP (measured up to 156 mg/L). The NUn score overall (calculated with this caveat) and a threshold of 10 was not found to have clinical utility in predicting AL or complications.
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Affiliation(s)
- J M Findlay
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - R C Tilson
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - A Harikrishnan
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - B Sgromo
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - R E K Marshall
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - N D Maynard
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - R S Gillies
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK
| | - M R Middleton
- NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK
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7
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Findlay JM, Bradley KM, Maile EJ, Braden B, Maw J, Phillips-Hughes J, Gillies RS, Maynard ND, Middleton MR. Pragmatic staging of oesophageal cancer using decision theory involving selective endoscopic ultrasonography, PET and laparoscopy. Br J Surg 2015; 102:1488-99. [PMID: 26458070 DOI: 10.1002/bjs.9905] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 02/05/2015] [Accepted: 06/23/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Following CT, guidelines for staging oesophageal and gastro-oesophageal junction (GOJ) cancer recommend endoscopic ultrasonography (EUS), PET-CT and laparoscopy for T3-T4 GOJ tumours. These recommendations are based on generic utilities, but it is unclear whether the test risk outweighs the potential benefit for some patients. This study sought to quantify investigation risks, benefits and utilities, in order to develop pragmatic, personalized staging recommendations. METHODS All patients with a histological diagnosis of oesophageal or GOJ cancer staged between May 2006 and July 2013 comprised a development set; those staged from July 2013 to July 2014 formed the prospective validation set. Probability thresholds of altering management were calculated and predictive factors identified. Algorithms and models (decision tree analysis, logistic regression, artificial neural networks) were validated internally and independently. RESULTS Some 953 patients were staged following CT, by [(18) F]fluorodeoxyglucose PET-CT (918), EUS (798) and laparoscopy (458). Of these patients, 829 comprised the development set (800 PET-CT, 698 EUS, 397 laparoscopy) and 124 the validation set (118 PET-CT, 100 EUS, 61 laparoscopy). EUS utility in the 71.8 per cent of patients with T2-T4a disease on CT was minimal (0.4 per cent), its risk exceeding benefit. EUS was moderately accurate for pT1 N0 disease. A number of factors predicted metastases on PET-CT and laparoscopy, although none could inform an algorithm. PET-CT altered management in 23.0 per cent, and laparoscopy in 7.1 per cent, including those with T2 and distal oesophageal tumours. CONCLUSION Although EUS provided additional information on T and N category, its risk outweighed potential benefit in patients with T2-T4a disease on CT. Laparoscopy seemed justified for distal oesophageal tumours of T2 or greater.
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Affiliation(s)
- J M Findlay
- Oxford OesophagoGastric Centre, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - K M Bradley
- Department of Radiology, Churchill Hospital, Oxford, UK
| | - E J Maile
- Oxford OesophagoGastric Centre, Oxford, UK
| | - B Braden
- Department of Gastroenterology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Maw
- Oxford OesophagoGastric Centre, Oxford, UK
| | | | | | | | - M R Middleton
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK.,Department of Oncology, University of Oxford, Oxford, UK
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8
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Findlay JM, Tustian E, Millo J, Klucniks A, Sgromo B, Marshall REK, Gillies RS, Middleton MR, Maynard ND. The effect of formalizing enhanced recovery after esophagectomy with a protocol. Dis Esophagus 2014; 28:567-73. [PMID: 24835109 DOI: 10.1111/dote.12234] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [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] [Indexed: 12/11/2022]
Abstract
Enhanced recovery after surgery (ERAS) pathways aim to accelerate functional return and discharge from hospital. They have proven effective in many forms of surgery, most notably colorectal. However, experience in esophagectomy has been limited. A recent study reported significant reductions in pulmonary complications, mortality, and length of stay following the introduction of an ERAS protocol alone, without the introduction of any clinical changes. We instituted a similar change 16 months ago, introducing a protocol to provide a formal framework, for our existing postoperative care. This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change. Data were collected from prospectively maintained secure web-based multidisciplinary databases. Complication severity was classified using the Clavien-Dindo scale. Operative mortality was defined as death within 30 days of surgery, or at any point during the same hospital admission. Lower respiratory tract infection was defined as clinical evidence of infection, with or without radiological signs. Respiratory complications included lower respiratory tract infection, pleural effusion (irrespective of drainage), pulmonary collapse, and pneumothorax. Statistical analysis was performed using SPSS v21. One hundred thirty-two patients underwent esophagectomy (55 protocol group; 77 before). All were performed open. There were no differences between the two groups in terms of age, gender, operation, use of neoadjuvant therapy, cell type, stage, tumor site, or American Society of Anesthesiologists grade. Median length of stay was 14.0 days (protocol) compared with 12.0 before (interquartile range 9-19 and 9.5-15.5, respectively; P = 0.073, Mann-Whitney U-test). Readmission within 30 days of discharge occurred in five (9.26%) and six (8.19%; P = 1.000, Fisher's exact test). There were four in-hospital deaths (3.03%): one (1.82%) and three (3.90%), respectively (P = 0.641). There were no differences in the severity of complications (P = non-significant; Pearson's chi-squared). There were no differences in the type of complications occurring in either group. The protocol was completed successfully by 26 (47.3%). No baseline factors were predictive of this. In contrast to previous studies, we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol. Consequently, improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care. Consequently, we would recommend that centers introducing new (or reviewing existing) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such standardized pathways.
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Affiliation(s)
- J M Findlay
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - E Tustian
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - J Millo
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - A Klucniks
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - B Sgromo
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - R E K Marshall
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - R S Gillies
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - M R Middleton
- Oxford NIHR Biomedical Research Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
| | - N D Maynard
- Oxford OesophagoGastric Centre, The Joint Research Office, Churchill Hospital, Oxford, UK
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9
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Gillies RS, Middleton MR, Han C, Marshall REK, Maynard ND, Bradley KM, Gleeson FV. Role of positron emission tomography-computed tomography in predicting survival after neoadjuvant chemotherapy and surgery for oesophageal adenocarcinoma. Br J Surg 2012; 99:239-45. [PMID: 22329010 DOI: 10.1002/bjs.7758] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Positron emission tomography combined with computed tomography (PET-CT) is increasingly being used in the staging of oesophageal cancer. Some recent reports suggest it may be used to predict survival. None of these studies, however, reported on the prognostic value of PET-CT performed before neoadjuvant chemotherapy and surgery. The aim of this study was to determine whether pretreatment PET-CT could predict survival. METHODS Consecutive patients with oesophageal adenocarcinoma who underwent PET-CT before neoadjuvant chemotherapy and resection were included. Maximum standardized uptake value (SUV(max)), fluorodeoxyglucose (FDG)-avid tumour length and the presence of FDG-avid local lymph nodes were determined for all patients. Kaplan-Meier survival analysis was performed and multivariable analysis used to identify independent prognostic factors. RESULTS A total of 121 patients were included (mean age 63 years, 97 men) of whom 103 underwent surgical resection. On an intention-to-treat basis, overall survival was significantly worse in patients with FDG-avid local lymph nodes (P < 0·001). SUV(max) and FDG-avid tumour length did not predict survival (P = 0·276 and P = 0·713 respectively). The presence of FDG-avid local lymph nodes was an independent predictor of poor overall survival (hazard ratio (HR) 4·75, 95 per cent confidence interval 2·14 to 10·54; P < 0·001) and disease-free survival (HR 2·97, 1·40 to 6·30; P = 0·004). CONCLUSION The presence of FDG-avid lymph nodes, but not SUV(max) or FDG-avid tumour length, was an independent adverse prognostic factor.
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Affiliation(s)
- R S Gillies
- Department of Oncology, Oxford Cancer and Haematology Centre, Oxford, UK.
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10
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Abstract
The left thoracoabdominal approach to esophagectomy is not widely performed, despite offering excellent exposure to tumors of the esophagogastric junction. Criticisms of the approach have focused on historically high rates of mortality, complications, and positive resection margins. Our aim was to determine whether left thoracoabdominal esophagectomy could combine a radical oncological resection with acceptably low mortality and morbidity. A retrospective cohort study of all left thoracoabdominal esophagectomies was performed at a single specialist center over an 11-year period. Primary outcomes were in-hospital mortality, complications, resection margin involvement, and lymph node yield; secondary outcomes were 1-year and 5-year survival. Two hundred eleven esophagectomies were performed. In-hospital mortality was 5.7% (12/211). One hundred one subjects (47.9%) had an uncomplicated recovery; 110 subjects (52.1%) developed at least one complication. There were 15 clinically significant anastomotic leaks (7.1%). Twenty-four subjects (11.4%) required emergency reoperation, the most common indication being anastomotic leakage. Complete tumor excision (R0 resection) was achieved in 151 of 211 cases (71.6%); median lymph node yield was 24. One-year and 5-year survival rates were 70% (147/211) and 21% (24/116), respectively. Left thoracoabdominal esophagectomy can combine a radical oncological resection with acceptably low mortality and morbidity.
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Affiliation(s)
- R S Gillies
- Department of Esophagogastric Surgery, Oxford Cancer and Hematology Centre, Churchill Hospital, Oxford, UK.
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Safranek PM, Sujendran V, Baron R, Warner N, Blesing C, Maynard ND. Oxford experience with neoadjuvant chemotherapy and surgical resection for esophageal adenocarcinomas and squamous cell tumors. Dis Esophagus 2008; 21:201-6. [PMID: 18430099 DOI: 10.1111/j.1442-2050.2007.00752.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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] [Indexed: 12/11/2022]
Abstract
The Medical Research Council trial for oesophageal cancer (OEO2) trial demonstrated a clear survival benefit from neoadjuvant chemotherapy in resectable esophageal carcinoma. Since February 2000 it has been our practice to offer this chemotherapy regime to patients with T2 and T3 or T1N1 tumors. We analyzed prospectively collected data of patients who received neoadjuvant chemotherapy prior to esophageal resection under the care of a single surgeon. Complications of treatment and overall outcomes were evaluated. A total of 194 patients had cisplatin and 5-fluorouracil prior to esophageal resection. Six patients (5.7%) had progressive disease and were inoperable (discovered in four at surgery). During chemotherapy one patient died and one perforated (operated immediately). Complications including severe neutropenia, coronary artery spasm, renal impairment and pulmonary edema led to the premature cessation of chemotherapy in 12 patients (6.2%). A total of 182 patients with a median age of 63 (range 30-80), 41 squamous and 141 adenocarcinomas underwent surgery. Operations were 91 left thoracoabdominal (50%), 45 radical transhiatal (25%), 40 Ivor-Lewis (22%) and six stage three (3%), and 78.6% had microscopically complete (R0) resections. Median survival was 28 months with 77.3% surviving for 1 year and 57.7% for 2 year. In hospital mortality was 5.5% and anastomotic leak rate 7.7%. A radical surgical approach to the primary tumor in combination with OEO2 neoadjuvant chemotherapy has led to a high R0 resection rate and good survival with acceptable morbidity and mortality.
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Affiliation(s)
- P M Safranek
- Department of Upper Gastrointestinal Surgery, Addenbrookes Hospital, Cambridge, UK
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Maynard ND. High-grade dysplasia in Barrett's oesophagus. The case for oesophageal resection. Ann R Coll Surg Engl 2007; 89:588-590. [PMID: 18210668] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Affiliation(s)
- N D Maynard
- Oxford Oesophago-Gastric Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK.
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Abstract
BACKGROUND AND AIMS It has been reported that gastric gastrointestinal stromal tumours (GIST) are aggressive, rare and difficult to treat. Some have advocated radical resection as the only potential cure. We present data to support treatment of gastric GISTs with a limited surgical approach and minimal morbidity. Furthermore, we propose that surveillance for recurrence is unnecessary based upon the follow-up of a cohort of patients with gastric GISTs. METHODS Database and case notes analysis of 20 patients diagnosed with gastric GIST (1998-2004) and managed by one surgeon in a single centre over seven years. Main outcome measures were inpatient adverse events, positive resection margins and symptom free survival. OUTCOMES Three cases have been managed with surveillance only. Successful resection was performed in 17 patients without mortality. No patient had positive margins on histological assessment. Fifteen out of seventeen samples were positive for the c-Kit proto-oncogene (CD117) and 14117 positive for CD34. Only two patients required en-bloc resections due to the tumour size and involvement of adjacent structures. One patient developed metastatic disease during follow-up of 19-86 months. CONCLUSIONS We recommend local excision of gastric GISTs to allow macroscopically clear margins. This policy then allows symptomatic follow-up due to the indolent nature of the majority of the tumours resected. A tailored follow-up with endoscopy and radiological imaging has been advocated by others but appears unnecessary in most cases. Imatinib (anti c-Kit) can now be offered to patients presenting with recurrent GIST, if further surgery is deemed inappropriate.
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Affiliation(s)
- V Sujendran
- Department of Upper Gl Surgery and Pathology, The John Radcliffe Hospital, Headington, Oxford, UK.
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Affiliation(s)
- G S Sica
- Department of Surgery, John Radcliffe Hospital, Headington, Oxford, UK.
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Prematilleke IV, Sujendran V, Warren BF, Maynard ND, Piris J. Granular cell tumour of the oesophagus mimicking a gastrointestinal stromal tumour on frozen section. Histopathology 2004; 44:502-3. [PMID: 15140000 DOI: 10.1111/j.1365-2559.2004.01820.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
STUDY OBJECTIVE To investigate the concept that splanchnic ischemia leads to hepatic dysfunction in the critically ill. DESIGN Prospective study and analysis of patient data. SETTING A general ICU in an inner-city London teaching hospital. PATIENTS Twenty-seven consecutive critically ill patients with evidence of inadequate tissue perfusion requiring pulmonary artery catheterization and mechanical ventilation. MEASUREMENTS In all patients, we measured the hepatic metabolism of lidocaine (lignocaine) to monoethylglycinexylidide (MEGX) and the clearance of indocyanine green (both dynamic, flow-dependent tests of hepatic function) over the first 3 days following admission to the ICU. These were compared with results of standard liver function tests and related to tonometric assessment of gastric intramucosal pH (pHim) and outcome. RESULTS There were no significant differences in bilirubin, aspartate aminotransferase, alkaline phosphatase, and prothrombin levels, or in indocyanine green clearance between survivors and nonsurvivors. On day 3, the median MEGX level was higher in survivors than in nonsurvivors (16 vs 2.4 ng/mL, p < 0.001), and the median MEGX level in nonsurvivors fell over the 3 days (20.6 to 2.4 ng/mL, p < 0.002). MEGX levels were significantly correlated with pHim (Spearman rank correlation coefficient [Rs] = 0.69, p < 0.001) as were the changes in the two measurements over the 3 days (Rs = 0.46, p < 0.02). The MEGX formation test and gastric pHim were the most discriminatory with regard to death and survival. CONCLUSIONS Our findings suggest that critically ill patients develop significant hepatic dysfunction that is associated with a poor outcome. This is likely to be due to a mismatch between hepatic metabolic demand and blood flow, and the MEGX formation test appears to be an extremely effective means of assessing liver function and flow in this group of patients.
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Affiliation(s)
- N D Maynard
- Department of Surgery, Guy's Hospital, London, United Kingdom
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Abstract
OBJECTIVE The mortality associated with repair of ruptured abdominal aortic aneurysms (RAAA) remains obstinately high and many deaths result from multiple organ failure which is likely to be related to splanchnic ischaemia. The aim of this study is to investigate the importance of splanchnic ischaemia in determining outcome from RAAA by comparing gastric intramucosal pH with other methods of assessing the adequacy of splanchnic oxygenation. DESIGN AND SETTING Prospective cohort of patients following surgery for RAAA admitted to the Intensive Care Unit of Guy's Hospital, London. OUTCOME MEASURES Gastric intramucosal pH (pHim) and global haemodynamic, oxygen transport and metabolic variables were measured on admission, at 12 h and at 24 h after admission. Results were compared between survivors and non-survivors and Receiver Operating Characteristic (ROC) curves were constructed to assess the ability of each measurement to predict outcome. RESULTS The median 24 h APACHE II was 18 and the ICU mortality 45.5%. Gastric pHim was significantly higher in survivors than non-survivors at 24 h (7.42 vs. 7.24, p < 0.01). In survivors who had a low intramucosal pH (pHim) on admission there was a significant improvement over the first 24 h (7.26 to 7.40, p < 0.05), whereas in patients who subsequently died, and had a normal pHim on admission, there was a significant fall in pHim (7.35 to 7.16, p < 0.05). ROC curves showed that gastric pHim was the most sensitive measurement for predicting outcome in these patients. CONCLUSIONS Gastric intramucosal pH is the most reliable indicator of adequacy of tissue oxygenation in patients with RAAA, suggesting that splanchnic ischaemia may have played an important role in determining survival.
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Affiliation(s)
- N D Maynard
- Department of Surgery, Guy's Hospital, London, U.K
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Abstract
STUDY OBJECTIVE To assess the effect of low dose dopexamine and dopamine on splanchnic blood flow as measured by gastric intramucosal pH, hepatic metabolism of lidocaine (lignocaine) to monoethylglycinexy-lidide (MEGX), and plasma disappearance rate of indocyanine green (ICG). DESIGN Single-blind randomization of patients with a gastric intramucosal acidosis to receive dopexamine (ten patients), dopamine (ten patients), or saline solution (five control patients) for 2 h. SETTING All 25 patients were in the ICU of Guys' Hospital. PATIENTS All patients met the criteria for the diagnosis of the systemic inflammatory response syndrome, were mechanically ventilated, and had pulmonary artery catheters placed. All had a low gastric intramucosal pH and had a median first 24-h acute physiology and chronic health evaluation (II) score of 22 (range, 7 to 40). MEASUREMENTS AND INTERVENTIONS Baseline measurements of gastric intramucosal pH, MEGX formation from lidocaine, ICG plasma disappearance rate, heart rate, mean arterial pressure, pulmonary artery occlusion pressure, cardiac index, oxygen delivery index, oxygen uptake index, systemic vascular resistance, and arterial pH were taken. Dopexamine (1 mg.kg-1.min-1), dopamine (2.5 mg.kg-1.min-1), or 0.9% saline solution was then infused for 2 h, after which a repeated set of the measurements was taken. RESULTS Dopexamine at a low dose had no effect on any of the systemic measurements. The median intramucosal pH rose from 7.23 to 7.35 (p < 0.005), the median ICG plasma disappearance rate from 7.6 to 11.3%.min-1 (p < 0.02), and the median MEGX concentration from 4 to 10.2 ng.mL-1 (p < 0.005). Dopamine had no effect on any of the measured variables. There were no changes in the control group. CONCLUSIONS Low-dose dopexamine increases splanchnic blood flow as measured by gastric intramucosal pH, MEGX formation from lidocaine, and ICG clearance. The lack of any change in the systemic measurements suggests that these effects are the result of a selective vasodilatation of the splanchnic vessels. At the dose used in this study, dopamine had no effect on splanchnic blood flow. Dopexamine may be useful in the management of splanchnic ischemia in the critically ill.
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Affiliation(s)
- N D Maynard
- Department of Surgery, Guy's Hospital, London, United Kingdom
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