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Phillips AW, Griffin SM. Three decades of oesophagogastric cancer care: now a curable disease. Br J Surg 2021; 108:595-597. [PMID: 33748863 DOI: 10.1093/bjs/znab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 12/31/2022]
Affiliation(s)
- A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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2
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Affiliation(s)
- A W Phillips
- Northern Oesophagogastric Unit, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
| | - S K Kamarajah
- Northern Oesophagogastric Unit, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
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Kamarajah SK, Newton N, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. Long-term outcomes of clinical and pathological-staged T3 N3 esophageal cancer. Dis Esophagus 2020; 33:5707333. [PMID: 31950184 DOI: 10.1093/dote/doz109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 06/23/2019] [Revised: 12/12/2019] [Indexed: 12/11/2022]
Abstract
Locally advanced esophageal cancer is associated with poor long-term survival. Pre- and post-treatment stages may differ because of neoadjuvant therapy and inaccuracies in staging. The aim of this study was to determine the outcomes of patients staged with clinical T3 N3 and pathological T3 N3 carcinoma of the esophagus and determine differences between the groups. Consecutive patients from a single unit between 2010 and 2018 were included with either clinical (cT3 N3) or pathological (pT3 N3) esophageal cancer. Outcomes were compared between patients that underwent esophagectomy with or without neoadjuvant treatment and those patients staged cT3 N3 treated non-surgically (NSR). Patients were staged using the TNM 8. This study included 156 patients, 63 patients were staged cT3 N3 initially and had NSR treatment, only three of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were initially staged as cT3 N3, 54 were found to be pT3 N3 having been staged earlier initially, and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3 N3 patients was significantly longer than pT3 N3 and NSR (median: NR vs 19 vs 8 months, P < 0.001). Twenty-seven patients with cT3 N3 had lower staging following treatment, while three had a higher stage. T3 N3 disease carries a poor prognosis. Within this cohort, cT3 N3 disease treated surgically has a high 5-year OS suggesting possible over-staging and stage migration due to neoadjuvant therapy. Those not having surgery, have a dismal prognosis. The impact of neoadjuvant treatment cannot be predicted and, current staging modalities may be inaccurate. Clinical stage should be used with caution when counseling patients regarding management and prognosis.
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Affiliation(s)
- S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK
| | - N Newton
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - S Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - A Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - N Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK.,School of Medical Education, Newcastle University, Newcastle-Upon-Tyne, UK
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Munro SP, Phillips AW, Griffin SM. Bleeding gastric ulcer from a pulmonary artery 20 years post-oesophagectomy: a common presentation with a rare cause. Ann R Coll Surg Engl 2020; 102:e1-e3. [PMID: 32735117 DOI: 10.1308/rcsann.2020.0152] [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: 11/22/2022] Open
Abstract
This case presents an unusually late complication of oesophagectomy 20-years post-surgery, with upper gastrointestinal bleeding. Further investigation revealed a gastric conduit ulcer eroding into the lower lobe of the right lung, forming a fistula with a basal branch of the right pulmonary artery. Upon successful embolisation, the HydroCoil® was visible on endoscopy. This case highlights the need for lifetime proton pump inhibitor cover post-oesophagectomy and demonstrates that when approaching uncommon presentations of common problems, careful consideration to treatment technique is essential.
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Affiliation(s)
- S P Munro
- Newcastle University Medical School, Newcastle upon Tyne, UK
| | - A W Phillips
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- President, Royal College of Surgeons of Edinburgh, Edinburgh, UK
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Kamarajah SK, Navidi M, Griffin SM, Phillips AW. Impact of anastomotic leak on long-term survival in patients undergoing gastrectomy for gastric cancer. Br J Surg 2020; 107:1648-1658. [PMID: 32533715 DOI: 10.1002/bjs.11749] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/20/2020] [Accepted: 05/11/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The impact of anastomotic leak (AL) on long-term outcomes after gastrectomy for gastric adenocarcinoma is poorly understood. This study determined whether AL contributes to poor overall survival. METHODS Consecutive patients undergoing gastrectomy in a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathological characteristics, oncological and postoperative outcomes were stratified according to whether patients had no AL, non-severe AL or severe AL. Severe AL was defined as anastomotic leakage associated with Clavien-Dindo Grade III-IV complications. RESULTS The study included 969 patients, of whom 58 (6·0 per cent) developed AL; 15 of the 58 patients developed severe leakage. Severe AL was associated with prolonged hospital stay (median 50, 30 and 13 days for patients with severe AL, non-severe AL and no AL respectively; P < 0·001) and critical care stay (median 11, 0 and 0 days; P < 0·001). There were no significant differences between groups in number of lymph nodes harvested (median 29, 30 and 28; P = 0·528) and R1 resection rates (7, 5 and 6·5 per cent; P = 0·891). Cox multivariable regression analysis showed that severe AL was independently associated with overall survival (hazard ratio 3·96, 95 per cent c.i. 2·11 to 7·44; P < 0·001) but not recurrence-free survival. In sensitivity analysis, the results for patients who had neoadjuvant therapy then gastrectomy were similar to those for the entire cohort. CONCLUSION AL prolongs hospital stay and is associated with compromised long-term overall survival.
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Affiliation(s)
- S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
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Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. Significance of Neoadjuvant Downstaging in Carcinoma of Esophagus and Gastroesophageal Junction. Ann Surg Oncol 2020; 27:3182-3192. [PMID: 32201923 PMCID: PMC7410857 DOI: 10.1245/s10434-020-08358-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 11/11/2019] [Indexed: 01/01/2023]
Abstract
Objective To determine the impact of downstaging on outcomes in esophageal cancer, the prognostic value of clinical and pathological stage, and the difference in survival in patients with similar pathological stages with and without neoadjuvant treatment. Background There is little data evaluating adenocarcinoma and squamous cell carcinoma (SCC) and difference in outcomes for similar pathological stage with and without neoadjuvant treatment. Patients and Methods Consecutive patients with esophageal cancer from a single center were evaluated. Patients with esophageal adenocarcinoma or SCC treated with transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM 8th edition was used. Results This study included 992 patients, of whom 417 received surgery alone and 575 received neoadjuvant therapy and surgery. In the neoadjuvant group, 7 (1%) had cTNM stage 2 and 418 (73%) had cTNM stage 3. Downstaging rates were similar between adenocarcinoma and SCC (54% vs. 61%, p = 0.5). Downstaging was associated with longer survival than patients with no change (adenocarcinoma, median: 82 vs. 26 months, p < 0.001; SCC, median: NR vs. 29 months, p < 0.001). On Cox regression analysis, downstaging was associated with significantly longer survival in adenocarcinoma but not in SCC. For SCC and more advanced adenocarcinoma, overall survival was significantly better when comparing like-for-like ypTN to pTN groups. Conclusions Pathological stage provides a better estimate of prognosis compared with clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage who did not receive neoadjuvant treatment. Electronic supplementary material The online version of this article (10.1245/s10434-020-08358-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
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Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. Anastomotic Leak Does Not Impact on Long-Term Outcomes in Esophageal Cancer Patients. Ann Surg Oncol 2020; 27:2414-2424. [PMID: 31974709 PMCID: PMC7311371 DOI: 10.1245/s10434-020-08199-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 09/01/2019] [Indexed: 12/18/2022]
Abstract
Background Esophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence. Objective The aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer. Methods Consecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien–Dindo grade III/IV complications. Results This study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days; p < 0.001) and prolonged hospital stay (median 43 vs. 27 vs. 15 days; p < 0.001) compared with NSL or no AL. There were no significant differences in number of lymph nodes harvested and rates of R1 resection between groups. OS and RFS were not affected by either NSL or SEAL, and Cox multivariate regression showed NSL and SEAL were not independently associated with OS and RFS. Sensitivity analysis in patients receiving neoadjuvant therapy followed by esophagectomy demonstrated similar findings. Conclusion These results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact.
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Affiliation(s)
- S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
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Navidi M, Madhavan A, Griffin SM, Prasad P, Immanuel A, Hayes N, Phillips AW. Trainee performance in radical gastrectomy and its effect on outcomes. BJS Open 2019; 4:86-90. [PMID: 32011816 PMCID: PMC6996638 DOI: 10.1002/bjs5.50219] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 02/17/2019] [Accepted: 07/19/2019] [Indexed: 12/16/2022] Open
Abstract
Background This study aimed to determine whether trainee involvement in D2 gastrectomies was associated with adverse outcomes. Methods Data from a prospectively created database of consecutive patients undergoing open D2 total (TG) or subtotal (STG) gastrectomy with curative intent between January 2009 and January 2014 were reviewed. Short‐ and long‐term clinical outcomes were compared in patients operated on by consultants and those treated by trainees under consultant supervision. Results A total of 272 D2 open gastrectomies were performed, 123 (45·2 per cent) by trainees. There was no significant difference between consultants and trainees in median duration of surgery (TG: 240 (range 102–505) versus 240 (170–375) min respectively, P = 0·452; STG: 225 (150–580) versus 212 (125–380) min, P = 0·192), number of resected nodes (TG: 30 (13–101) versus 30 (11–102), P = 0·681; STG: 26 (5–103) versus 25 (1–63), P = 0·171), length of hospital stay (TG: 15 (7–78) versus 15 (8–65) days, P = 0·981; STG: 10 (6–197) versus 14 (7–85) days, P = 0·242), overall morbidity (TG: 44 versus 49 per cent, P = 0·314; STG: 34 versus 25 per cent, P = 0·113) or mortality (TG: 4 versus 2 per cent; P = 0·293). No difference in predicted 5‐year overall survival was noted between the two cohorts (TG: 68 per cent for consultants versus 77 per cent for trainees, P = 0·254; STG: 70 versus 75 per cent respectively, P = 0·512). The trainee cohort had lower median blood loss for both TG (360 (range 90–1200) ml versus 600 (70–2350) ml for consultants; P = 0·042) and STG (235 (50–1000) versus 360 (50–3000) ml respectively; P = 0·053). Conclusion Clinical outcomes were not compromised by supervised trainee involvement in D2 open gastrectomy.
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Affiliation(s)
- M Navidi
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - A Madhavan
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - P Prasad
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - A Immanuel
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - N Hayes
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - A W Phillips
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
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Phillips AW, Hardy K, Navidi M, Kamarajah SK, Madhavan A, Immanuel A, Griffin SM. Impact of Lymphadenectomy on Survival After Unimodality Transthoracic Esophagectomy for Adenocarcinoma of Esophagus. Ann Surg Oncol 2019; 27:692-700. [DOI: 10.1245/s10434-019-07905-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Indexed: 01/04/2023]
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Konradsson M, van Berge Henegouwen MI, Bruns C, Chaudry MA, Cheong E, Cuesta MA, Darling GE, Gisbertz SS, Griffin SM, Gutschow CA, van Hillegersberg R, Hofstetter W, Hölscher AH, Kitagawa Y, van Lanschot JJB, Lindblad M, Ferri LE, Low DE, Luyer MDP, Ndegwa N, Mercer S, Moorthy K, Morse CR, Nafteux P, Nieuwehuijzen GAP, Pattyn P, Rosman C, Ruurda JP, Räsänen J, Schneider PM, Schröder W, Sgromo B, Van Veer H, Wijnhoven BPL, Nilsson M. Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process. Dis Esophagus 2019; 33:5585602. [PMID: 31608938 PMCID: PMC7150655 DOI: 10.1093/dote/doz074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/25/2019] [Accepted: 07/14/2019] [Indexed: 12/11/2022]
Abstract
Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.
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Affiliation(s)
- M Konradsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Gastroenterology, Landspitali National University Hospital, Reykjavik, Iceland,Address correspondence to: Magnus Konradsson, MD, Department of Clinical Science, Investigation and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden.
| | - M I van Berge Henegouwen
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - C Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - E Cheong
- Norfolk and Norwich University Hospital, Norwich, UK
| | - M A Cuesta
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - G E Darling
- Department of Surgery, Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - S S Gisbertz
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - C A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - W Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A H Hölscher
- Centre for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L E Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D E Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - M D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - N Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - S Mercer
- Queen Alexandra Hospital Portsmouth, United Kingdom
| | - K Moorthy
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - C R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | | | - P Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - C Rosman
- Department of surgery, Radboud university center Nijmegen, The Netherlands
| | - J P Ruurda
- Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - J Räsänen
- Department of General, Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - P M Schneider
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - B Sgromo
- Oxford University Hospitals, Oxford, UK
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Surgery and Cancer, Imperial College London, London, UK
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Allum WH, Smyth EC, Blazeby JM, Grabsch HI, Griffin SM, Rowley S, Cafferty FH, Langley RE, Cunningham D. Quality assurance of surgery in the randomized ST03 trial of perioperative chemotherapy in carcinoma of the stomach and gastro-oesophageal junction. Br J Surg 2019; 106:1204-1215. [PMID: 31268180 PMCID: PMC6771829 DOI: 10.1002/bjs.11184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 11/04/2018] [Revised: 02/12/2019] [Accepted: 02/26/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND The UK Medical Research Council ST03 trial compared perioperative epirubicin, cisplatin and capecitabine (ECX) chemotherapy with or without bevacizumab (B) in gastric and oesophagogastric junctional cancer. No difference in survival was noted between the arms of the trial. The present study reviewed the standards and performance of surgery in the context of the protocol-specified surgical criteria. METHODS Surgical and pathological clinical report forms were reviewed to determine adherence to the surgical protocols, perioperative morbidity and mortality, and final histopathological stage for all patients treated in the study. RESULTS Of 1063 patients randomized, 895 (84·2 per cent) underwent resection; surgical details were available for 880 (98·3 per cent). Postoperative assessment data were available for 873 patients; complications occurred in 458 (52·5 per cent) overall, of whom 71 (8·1 per cent) developed complications deemed to be life-threatening by the responsible clinician. The most common complications were respiratory (211 patients, 24·2 per cent). The anastomotic leak rate was 118 of 873 (13·5 per cent) overall; among those who underwent oesophagogastrectomy, the rate was higher in the group receiving ECX-B (23·6 per cent versus 9·9 per cent in the ECX group). Pathological assessment data were available for 845 patients. At least 15 nodes were removed in 82·5 per cent of resections and the median lymph node harvest was 24 (i.q.r. 17-34). Twenty-five or more nodes were removed in 49·0 per cent of patients. Histopathologically, the R1 rate was 24·9 per cent (208 of 834 patients). An R1 resection was more common for proximal tumours. CONCLUSION In the ST03 trial, the performance of surgery met the protocol-stipulated criteria. Registration number: NCT00450203 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- W. H. Allum
- Gastrointestinal UnitRoyal Marsden NHS Foundation TrustLondonUK
| | - E. C. Smyth
- Gastrointestinal UnitRoyal Marsden NHS Foundation TrustLondonUK
| | - J. M. Blazeby
- Bristol Centre for Surgical ResearchBristol Medical School, University of BristolBristolUK
| | - H. I. Grabsch
- Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, School of MedicineUniversity of LeedsLeedsUK
- Department of Pathology, GROW School for Oncology and Developmental BiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - S. M. Griffin
- Department of Gastrointestinal SurgeryRoyal Victoria InfirmaryNewcastle upon TyneUK
| | - S. Rowley
- Medical Research Council Clinical Trials Unit at University College LondonLondonUK
| | - F. H. Cafferty
- Medical Research Council Clinical Trials Unit at University College LondonLondonUK
| | - R. E. Langley
- Medical Research Council Clinical Trials Unit at University College LondonLondonUK
| | - D. Cunningham
- Gastrointestinal UnitRoyal Marsden NHS Foundation TrustLondonUK
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12
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Navidi M, Phillips AW, Griffin SM, Duffield KE, Greystoke A, Sumpter K, Sinclair RCF. Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer. Br J Surg 2018. [PMID: 29601082 DOI: 10.1002/bjs.10802)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy may have a detrimental impact on cardiorespiratory reserve. Determination of oxygen uptake at the anaerobic threshold by cardiopulmonary exercise testing (CPET) provides an objective measure of cardiorespiratory reserve. Anaerobic threshold can be used to predict perioperative risk. A low anaerobic threshold is associated with increased morbidity after oesophagogastrectomy. The aim of this study was to establish whether neoadjuvant chemotherapy has an adverse effect on fitness, and whether there is recovery of fitness before surgery for oesophageal and gastric adenocarcinoma. METHODS CPET was completed before, immediately after (week 0), and at 2 and 4 weeks after neoadjuvant chemotherapy. The ventilatory anaerobic threshold and peak oxygen uptake (Vo2 peak) were used as objective, reproducible measures of cardiorespiratory reserve. Anaerobic threshold and Vo2 peak were compared before and after neoadjuvant chemotherapy, and at the three time intervals. RESULTS Some 31 patients were recruited. The mean anaerobic threshold was lower following neoadjuvant treatment: 15·3 ml per kg per min before chemotherapy versus 11·8, 12·1 and 12·6 ml per kg per min at week 0, 2 and 4 respectively (P < 0·010). Measurements were also significantly different at each time point (P < 0·010). The same pattern was noted for Vo2 peak between values before chemotherapy (21·7 ml per kg per min) and at weeks 0, 2 and 4 (17·5, 18·6 and 19·3 ml per kg per min respectively) (P < 0·010). The reduction in anaerobic threshold and Vo2 peak did not improve during the time between completion of neoadjuvant chemotherapy and surgery. CONCLUSION There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.
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Affiliation(s)
- M Navidi
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K E Duffield
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Greystoke
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - K Sumpter
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - R C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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13
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Donohoe CL, Phillips AW, Flynn E, Donnison C, Taylor CL, Sinclair RCF, Saunders D, Immanuel A, Griffin SM. Multimodal analgesia using intrathecal diamorphine, and paravertebral and rectus sheath catheters are as effective as thoracic epidural for analgesia post-open two-phase esophagectomy within an enhanced recovery program. Dis Esophagus 2018; 31:5003208. [PMID: 29800270 DOI: 10.1093/dote/doy006] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Thoracic epidural (TE) analgesia has been the standard of care for transthoracic esophagectomy patients since the 1990s. Multimodal anesthesia using intrathecal diamorphine, local anesthetic infusion catheters (LAC) into the paravertebral space and rectus sheaths and intravenous opioid postoperatively represent an alternative option for postoperative analgesia. While TE can provide excellent pain control, it may inhibit early postoperative recovery by causing hypotension and reducing mobilization. The aim of this study is to determine whether multimodal analgesia with LAC was effective with respect to adequate pain management, and compare its impact on hypotension and mobility. Patients receiving multimodal LAC analgesia were matched using propensity score matching to patients undergoing two-phase trans-thoracic esophagectomy with a TE over a two-year period (from January 2015 to December 2016). Postoperative endpoints that had been evaluated prospectively, including pain scores on movement and at rest, inotrope or vasoconstrictor requirements, and hypotension (systolic BP < 90 mmHg), were compared between cohorts. Out of 14 patients (13 male) that received LAC were matched to a cohort of 14 patients on age, sex, and comorbidity. Mean and maximum pain scores at rest and movement on postoperative days 0 to 3 were equivalent between the groups. In both cohorts, 50% of patients had a pain score of more than 7 on at least one occasion. Fewer patients in the LAC group required vasoconstrictor infusion (LAC: 36% vs. TE: 57%, P = 0.256) to maintain blood pressure or had episodes of hypotension (LAC: 43% vs. TE: 79%, P = 0.05). The LAC group was more able to ambulate on the first postoperative day (LAC: 64% vs. TE: 43%, P = 0.14) but these differences were not statistically significant. Within the epidural cohort, three patients had interruption of epidural due to dislodgement or failure of block compared to no disruption in the multimodal local anesthesia catheters group (P = 0.05). Therefore, multimodal anesthesia using spinal diamorphine with combined paravertebral and rectus sheath local anesthetic catheters appears to provide comparable pain relief post two-phase esophagectomy and may provide more reliable and safe analgesia than the current standard of care.
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Affiliation(s)
- C L Donohoe
- Departments of Surgery, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - A W Phillips
- Departments of Surgery, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - E Flynn
- Anaesthesia and Critical Care Medicine, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - C Donnison
- Anaesthesia and Critical Care Medicine, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - C L Taylor
- Departments of Surgery, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - R C F Sinclair
- Anaesthesia and Critical Care Medicine, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - D Saunders
- Anaesthesia and Critical Care Medicine, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - A Immanuel
- Departments of Surgery, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - S M Griffin
- Departments of Surgery, Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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14
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Munro CE, Stamp GFW, Phillips AW, Griffin SM. A tale of three stents: aortic stenting prior to oesophagectomy after oesophageal stents. Ann R Coll Surg Engl 2018; 100:e78-e80. [PMID: 29364021 PMCID: PMC5958853 DOI: 10.1308/rcsann.2018.0009] [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] [Accepted: 12/03/2017] [Indexed: 11/22/2022] Open
Abstract
The use of endoluminal stents to treat anastomotic leaks post oesophagogastric resection remains controversial. While some advocate stents to expedite recovery, others advise caution due to the risk of major morbidity and mortality. We describe a case of anastomotic leak following total gastrectomy for adenocarcinoma treated with a self-expanding metallic stent. Complications with the initial stent were treated with a further stent, which compromised the function of the oesophagus and eroded into the aorta, necessitating a colonic reconstruction and endovascular aortic stenting.
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Affiliation(s)
- CE Munro
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - GFW Stamp
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - AW Phillips
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - SM Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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15
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Navidi M, Phillips AW, Griffin SM, Duffield KE, Greystoke A, Sumpter K, Sinclair RCF. Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer. Br J Surg 2018; 105:900-906. [DOI: 10.1002/bjs.10802] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/19/2017] [Accepted: 11/27/2017] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Neoadjuvant chemotherapy may have a detrimental impact on cardiorespiratory reserve. Determination of oxygen uptake at the anaerobic threshold by cardiopulmonary exercise testing (CPET) provides an objective measure of cardiorespiratory reserve. Anaerobic threshold can be used to predict perioperative risk. A low anaerobic threshold is associated with increased morbidity after oesophagogastrectomy. The aim of this study was to establish whether neoadjuvant chemotherapy has an adverse effect on fitness, and whether there is recovery of fitness before surgery for oesophageal and gastric adenocarcinoma.
Methods
CPET was completed before, immediately after (week 0), and at 2 and 4 weeks after neoadjuvant chemotherapy. The ventilatory anaerobic threshold and peak oxygen uptake (Vo2 peak) were used as objective, reproducible measures of cardiorespiratory reserve. Anaerobic threshold and Vo2 peak were compared before and after neoadjuvant chemotherapy, and at the three time intervals.
Results
Some 31 patients were recruited. The mean anaerobic threshold was lower following neoadjuvant treatment: 15·3 ml per kg per min before chemotherapy versus 11·8, 12·1 and 12·6 ml per kg per min at week 0, 2 and 4 respectively (P < 0·010). Measurements were also significantly different at each time point (P < 0·010). The same pattern was noted for Vo2 peak between values before chemotherapy (21·7 ml per kg per min) and at weeks 0, 2 and 4 (17·5, 18·6 and 19·3 ml per kg per min respectively) (P < 0·010). The reduction in anaerobic threshold and Vo2 peak did not improve during the time between completion of neoadjuvant chemotherapy and surgery.
Conclusion
There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.
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Affiliation(s)
- M Navidi
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K E Duffield
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Greystoke
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - K Sumpter
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - R C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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16
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Lagarde SM, Phillips AW, Navidi M, Disep B, Griffin SM. Clinical outcomes and benefits for staging of surgical lymph node mapping after esophagectomy. Dis Esophagus 2017; 30:1-7. [PMID: 28881884 DOI: 10.1093/dote/dox086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 10/17/2016] [Indexed: 12/11/2022]
Abstract
Dissection of lymph nodes (LN) immediately after esophagectomy is utilized by some surgeons to aid determination of LN stations involved in esophageal cancer. Some suggest that this increases LN yield and gives information regarding the pattern of lymphatic spread, others feel that this may compromise a circumferential resection margin (CRM) assessment. The aim of this study is to evaluate the effect of ex vivo dissection on the assessment of the CRM and the pattern of lymph node dissemination in patients with adenocarcinoma of the esophagus and gastroesophageal junction (GEJ) undergoing radical surgery after neoadjuvant chemotherapy and their prognostic impact. Data from consecutive patients with potentially curable adenocarcinoma of the distal esophagus and GEJ who received neoadjuvant treatment followed by surgery were analyzed. Clinical and pathological findings were reviewed and LN burden and location correlated with clinical outcome. Pathology specimens were dissected into individual LN groups 'ex-vivo' by the surgeon. A total of 301 patients were included: 295 had a radical proximal and distal resection margin however in 62(20.6%) CRM could not be assessed. A median of 33(10-77) nodes were recovered. A 117(38.9%) patients were ypN0 while 184(61.1%) were LN positive (ypN1-N3). LN stations close to the tumor were most frequently involved. Twenty-seven (14.7%) patients had only thoracic stations involved, 48(26.1%) only abdominal stations and 109 (59.2%) had both. Median survival for yN0 patients was 171 months compared to 24 months for those LN positive (P< 0.001). Multivariate analyses identified ypT-category, ypN-category, male gender, and nonradical resection (proximal or distal) margin as significant prognostic factors. Surgical dissection of nodes after esophagectomy enables accurate LN assessment, but may compromise CRM assessment in up to 20% of cases. It also provides valuable information regarding the pattern of nodal spread.
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Affiliation(s)
- S M Lagarde
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, UK.,Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A W Phillips
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, UK
| | - M Navidi
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, UK
| | - B Disep
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, UK
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17
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Markar SR, Mackenzie H, Wiggins T, Askari A, Karthikesalingam A, Faiz O, Griffin SM, Birkmeyer JD, Hanna GB. Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions. Br J Surg 2017; 105:113-120. [DOI: 10.1002/bjs.10640] [Citation(s) in RCA: 28] [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: 03/06/2017] [Revised: 04/27/2017] [Accepted: 06/07/2017] [Indexed: 01/19/2023]
Abstract
Abstract
Background
In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.
Methods
The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997–2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed.
Results
Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia.
Conclusion
Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.
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Affiliation(s)
- S R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Wiggins
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College London, London, UK
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - A Karthikesalingam
- St George's Vascular Institute, St George's, University of London, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College London, London, UK
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J D Birkmeyer
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
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18
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Sinclair RCF, Phillips AW, Navidi M, Griffin SM, Snowden CP. Pre-operative variables including fitness associated with complications after oesophagectomy. Anaesthesia 2017; 72:1501-1507. [DOI: 10.1111/anae.14085] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- R. C. F. Sinclair
- Department of Anaesthesia; Northern Oesophagogastric Cancer Unit; Royal Victoria Infirmary; Newcastle upon Tyne UK
| | - A. W. Phillips
- Northern Oesophagogastric Cancer Unit; Royal Victoria Infirmary; Newcastle upon Tyne UK
| | - M. Navidi
- Northern Oesophagogastric Cancer Unit; Royal Victoria Infirmary; Newcastle upon Tyne UK
| | - S. M. Griffin
- Northern Oesophagogastric Cancer Unit; Royal Victoria Infirmary; Newcastle upon Tyne UK
| | - C. P. Snowden
- Department of Anaesthesia; Northern Oesophagogastric Cancer Unit; Royal Victoria Infirmary; Newcastle upon Tyne UK
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19
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Reynolds JV, Preston SR, O’Neill B, Baeksgaard L, Griffin SM, Mariette C, Cuffe S, Cunningham M, Crosby T, Parker I, Hofland K, Hanna G, Svendsen LB, Donohoe CL, Muldoon C, O’Toole D, Johnson C, Ravi N, Jones G, Corkhill AK, Illsley M, Mellor J, Lee K, Dib M, Marchesin V, Cunnane M, Scott K, Lawner P, Warren S, O’Reilly S, O’Dowd G, Leonard G, Hennessy B, Dermott RM. ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS). BMC Cancer 2017; 17:401. [PMID: 28578652 PMCID: PMC5457631 DOI: 10.1186/s12885-017-3386-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [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] [Received: 04/07/2016] [Accepted: 05/25/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens. METHODS This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research. DISCUSSION This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG). TRIAL REGISTRATION NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.
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Affiliation(s)
- JV Reynolds
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - SR Preston
- Royal Surrey County Hospital, Guildford, UK
| | | | | | | | - C Mariette
- University Hospital C. Huriez Place de Verdun, Lille, France
| | - S Cuffe
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - M Cunningham
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - T Crosby
- Velindre Cancer Centre, Cardiff, Wales UK
| | - I Parker
- St Mary’s Hospital and Imperial College London, London, UK
| | | | - G Hanna
- St Mary’s Hospital and Imperial College London, London, UK
| | | | - CL Donohoe
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - C Muldoon
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - D O’Toole
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - C Johnson
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - N Ravi
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - G Jones
- Velindre Cancer Centre, Cardiff, Wales UK
| | - AK Corkhill
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - M Illsley
- Royal Surrey County Hospital, Guildford, UK
| | - J Mellor
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - K Lee
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - M Dib
- University Hospital C. Huriez Place de Verdun, Lille, France
| | - V Marchesin
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - M Cunnane
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - K Scott
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - P Lawner
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - S Warren
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - S O’Reilly
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - G O’Dowd
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - G Leonard
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - B Hennessy
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - R Mc Dermott
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
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20
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Johnson SW, Teachey AL, Valanejad SM, Griffin SM, Weber SF. Cure with ledipasvir/sofosbuvir for chronic hepatitis C virus in an individual with gastric bypass. J Clin Pharm Ther 2017; 42:624-626. [PMID: 28474386 DOI: 10.1111/jcpt.12547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/03/2017] [Indexed: 01/07/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The impact of gastric bypass surgery on the pharmacokinetics of various medications has been reported. Presently, no data exist for the treatment of chronic hepatitis C virus with ledipasvir/sofosbuvir (LDV/SOF) in an individual with a history of gastric bypass. CASE DESCRIPTION We report the successful cure of an individual who was treated with LDV/SOF who had a history of gastric bypass. The patient tolerated LDV/SOF well while only experiencing a minor headache. WHAT IS NEW AND CONCLUSION Ledipasvir/sofosbuvir treatment may still be effective in those with a history of gastric bypass surgery.
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Affiliation(s)
- S W Johnson
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA.,Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - A L Teachey
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - S M Valanejad
- Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - S M Griffin
- Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - S F Weber
- Infectious Diseases Specialist, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
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21
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Jagadesham VP, Lagarde SM, Immanuel A, Griffin SM. Systemic inflammatory markers and outcome in patients with locally advanced adenocarcinoma of the oesophagus and gastro-oesophageal junction. Br J Surg 2017; 104:401-407. [DOI: 10.1002/bjs.10425] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 10/07/2016] [Indexed: 01/09/2023]
Abstract
Abstract
Background
Raised levels of systemic inflammatory markers are associated with poor survival in patients with cancer. The aim of this study was to assess the prognostic value of markers of systemic inflammation in patients with adenocarcinoma of the oesophagus or gastro-oesophageal junction.
Methods
Data from a consecutive series of patients undergoing transthoracic oesophagectomy following neoadjuvant therapy at a single centre were analysed. Fibrinogen, albumin, C-reactive protein, leucocyte differential and platelet counts were measured before surgery. The upper quartile (75th percentile) was used as a cut-off for dichotomization. Multivariable regression analysis was performed to identify independent prognostic factors.
Results
A series of 199 patients underwent transthoracic oesophagectomy following neoadjuvant therapy. Univariable analysis indicated that reduced median survival was associated with a raised platelet : lymphocyte ratio (158 or above; 25.6 versus 44·4 months for patients with a normal ratio, P = 0·038) and increased fibrinogen levels (4·9 g/l or above; 22·8 versus 59·9 months for those with a normal level, P = 0·005). On multivariable analysis a combination of one or more markers of systemic inflammation was associated with poorer overall survival (hazard ratio 2·12, 95 per cent c.i. 1·20 to 3·74; P = 0·010).
Conclusion
Preoperative markers of systemic inflammation predict poor outcome in patients undergoing curative treatment for locally advanced oesophageal and gastro-oesophageal adenocarcinoma.
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Affiliation(s)
- V P Jagadesham
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - S M Lagarde
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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22
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Lagarde SM, Navidi M, Gisbertz SS, van Laarhoven HWM, Sumpter K, Meijer SL, Disep B, Immanuel A, Griffin SM, van Berge Henegouwen MI. Prognostic impact of extracapsular lymph node involvement after neoadjuvant therapy and oesophagectomy. Br J Surg 2016; 103:1658-1664. [PMID: 27696382 DOI: 10.1002/bjs.10226] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/29/2015] [Accepted: 05/09/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND The significance of extracapsular lymph node involvement (LNI) is unclear in patients with oesophageal cancer who have undergone neoadjuvant treatment followed by oesophagectomy. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in a large multicentre series of consecutive patients with oesophageal cancer treated by neoadjuvant chemotherapy or chemoradiotherapy and surgery. METHODS Data from a consecutive series of patients treated at two European centres were analysed. All patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastro-oesophageal junction, who received neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy with curative intent, were included. RESULTS Between January 2000 and September 2013, 704 patients underwent oesophagectomy after neoadjuvant therapy. A median of 28 (range 5-77) nodes per patient was recovered. Some 347 patients (49·3 per cent) had no LNI (ypN0). Of the remaining 357 patients (50·7 per cent) with LNI (ypN1-3), extracapsular LNI was found in 190 (53·2 per cent). Five-year overall survival rates were 62·7 per cent for patients with N0 disease, 44·9 per cent for patients without extracapsular spread and 14·0 per cent where extracapsular LNI was identified (P < 0·001). Multivariable analyses demonstrated the presence of extracapsular LNI as an independent prognostic factor. CONCLUSION The presence of extracapsular LNI after neoadjuvant therapy carries a poor prognosis.
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Affiliation(s)
- S M Lagarde
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M Navidi
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
| | - S S Gisbertz
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - H W M van Laarhoven
- Departments of Medical Oncology, Academic Medical Centre, Amsterdam, The Netherlands
| | - K Sumpter
- Departments of Oncology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S L Meijer
- Departments of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B Disep
- Departments of Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Rice TW, Apperson-Hansen C, DiPaola LM, Semple ME, Lerut TEMR, Orringer MB, Chen LQ, Hofstetter WL, Smithers BM, Rusch VW, Wijnhoven BPL, Chen KN, Davies AR, D’Journo XB, Kesler KA, Luketich JD, Ferguson MK, Räsänen JV, van Hillegersberg R, Fang W, Durand L, Allum WH, Cecconello I, 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, Ishwaran H, Blackstone EH. Worldwide Esophageal Cancer Collaboration: clinical staging data. Dis Esophagus 2016; 29:707-714. [PMID: 27731549 PMCID: PMC5591441 DOI: 10.1111/dote.12493] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [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] [Indexed: 02/05/2023]
Abstract
To address uncertainty of whether clinical stage groupings (cTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for clinically staged patients from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 22,123 clinically staged patients, 8,156 had squamous cell carcinoma, 13,814 adenocarcinoma, 116 adenosquamous carcinoma, and 37 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (18.5-25 mg/kg2 , 47%), little weight loss (2.4 ± 7.8 kg), 0-1 ECOG performance status (67%), and history of smoking (67%). Cancers were cT1 (12%), cT2 (22%), cT3 (56%), cN0 (44%), cM0 (95%), and cG2-G3 (89%); most involved the distal esophagus (73%). Non-risk-adjusted survival for squamous cell carcinoma was not distinctive for early cT or cN; for adenocarcinoma, it was distinctive for early versus advanced cT and for cN0 versus cN+. Patients with early cancers had worse survival and those with advanced cancers better survival than expected from equivalent pathologic categories based on prior WECC pathologic data. Thus, clinical and pathologic categories do not share prognostic implications. This makes clinically based treatment decisions difficult and pre-treatment prognostication inaccurate. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient characteristics, cancer categories, and treatment characteristics and should direct 9th edition data collection.
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Affiliation(s)
| | | | | | | | | | | | - L.-Q. Chen
- West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | | | - B. M. Smithers
- University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - V. W. Rusch
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | | | | | | | - 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
| | | | | | - W. Fang
- Shanghai Chest Hospital, Shanghai, China
| | - L. Durand
- Hospital de Clinicas, University of Buenos Aires, Buenos Aires, Argentina
| | - W. H. Allum
- Royal Marsden NHS Foundation Trust, London, UK
| | | | - R. J. Cerfolio
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - M. Pera
- Hospital Universitario del Mar, Barcelona, Spain
| | | | - R. Burger
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - J.-F Liu
- Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | | | - S. Law
- University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China
| | - T. J. Watson
- University of Rochester, Rochester, New York, USA
| | | | - 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 and Science University, Portland, Oregon, USA
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24
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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.
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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
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Rice TW, Lerut TEMR, Orringer MB, Chen LQ, Hofstetter WL, Smithers BM, Rusch VW, van Lanschot J, Chen KN, Davies AR, D’Journo XB, Kesler KA, Luketich JD, Ferguson MK, Rasanen JV, van Hillegersberg R, Fang W, Durand L, Allum WH, Cecconello I, 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, Ishwaran H, Apperson-Hansen C, DiPaola LM, Semple ME, Blackstone EH. Worldwide Esophageal Cancer Collaboration: neoadjuvant pathologic staging data. Dis Esophagus 2016; 29:715-723. [PMID: 27731548 PMCID: PMC5528175 DOI: 10.1111/dote.12513] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [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: 02/24/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 02/05/2023]
Abstract
To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. 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.
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Affiliation(s)
| | | | | | - L.-Q. Chen
- West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | | | - 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. 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
| | | | | | - W. Fang
- Shanghai Chest Hospital, Shanghai, China
| | - L. Durand
- Hospital de Clinicas, University of Buenos Aires, Buenos Aires, Argentina
| | - W. H. Allum
- Royal Marsden NHS Foundation Trust, London, UK
| | | | - R. J. Cerfolio
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - M. Pera
- Hospital Universitario del Mar, Barcelona, Spain
| | | | - R. Burger
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - J.-F. Liu
- Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | | | - S. Law
- University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China
| | - T. J. Watson
- University of Rochester, Rochester, New York, USA
| | | | - 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
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26
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Sinclair R, Navidi M, Griffin SM, Sumpter K. The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma. Ann R Coll Surg Engl 2016. [PMID: 27138851 DOI: 10.1308/rcsann.2016.0135)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Introduction Operable oesophagogastric adenocarcinoma management in the UK includes three cycles of neoadjuvant chemotherapy (NAC) followed by resection. Determination of oxygen uptake at the anaerobic threshold (AT) with cardiopulmonary exercise testing (CPET) is used to objectively measure cardiorespiratory reserve. Oxygen uptake at AT predicts perioperative risk, with low values associated with increased morbidity. Previous studies indicate NAC may have a detrimental impact on cardiorespiratory reserve. Methods CPET was completed by 30 patients before and after a standardised NAC protocol. The ventilatory AT was determined using the V-slope method, and the peak oxygen uptake and ventilatory equivalents for carbon dioxide measured. Median AT before and after chemotherapy was compared using a paired Student's t-test. Results Median oxygen uptake at AT pre- and post-NAC was 13.9±3.1 ml/kg/min and 11.5±2.0 ml/kg/min, respectively. The mean decrease was 2.4 ml/kg/min (95% confidence interval [CI] 1.3-3.85; p<0.001). Median peak oxygen delivery also decreased by 2.17 ml/kg/min (95% CI 1.02-3.84; p=0.001) after NAC. Ventilatory equivalents were unchanged. Conclusions This reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after NAC. Patients with lower cardiorespiratory reserve have increased postoperative morbidity and mortality. Preventing this decrease in cardiorespiratory reserve during chemotherapy, or optimising the timing of surgical resection after recovery of AT, may allow perioperative risk-reduction.
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Affiliation(s)
- Rcf Sinclair
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - M Navidi
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - S M Griffin
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - K Sumpter
- Freeman Hospital , Newcastle-upon-Tyne , UK
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Sinclair R, Navidi M, Griffin SM, Sumpter K. The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma. Ann R Coll Surg Engl 2016; 98:396-400. [PMID: 27138851 PMCID: PMC5209965 DOI: 10.1308/rcsann.2016.0135] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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] [Accepted: 12/31/2015] [Indexed: 01/09/2023] Open
Abstract
Introduction Operable oesophagogastric adenocarcinoma management in the UK includes three cycles of neoadjuvant chemotherapy (NAC) followed by resection. Determination of oxygen uptake at the anaerobic threshold (AT) with cardiopulmonary exercise testing (CPET) is used to objectively measure cardiorespiratory reserve. Oxygen uptake at AT predicts perioperative risk, with low values associated with increased morbidity. Previous studies indicate NAC may have a detrimental impact on cardiorespiratory reserve. Methods CPET was completed by 30 patients before and after a standardised NAC protocol. The ventilatory AT was determined using the V-slope method, and the peak oxygen uptake and ventilatory equivalents for carbon dioxide measured. Median AT before and after chemotherapy was compared using a paired Student's t-test. Results Median oxygen uptake at AT pre- and post-NAC was 13.9±3.1 ml/kg/min and 11.5±2.0 ml/kg/min, respectively. The mean decrease was 2.4 ml/kg/min (95% confidence interval [CI] 1.3-3.85; p<0.001). Median peak oxygen delivery also decreased by 2.17 ml/kg/min (95% CI 1.02-3.84; p=0.001) after NAC. Ventilatory equivalents were unchanged. Conclusions This reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after NAC. Patients with lower cardiorespiratory reserve have increased postoperative morbidity and mortality. Preventing this decrease in cardiorespiratory reserve during chemotherapy, or optimising the timing of surgical resection after recovery of AT, may allow perioperative risk-reduction.
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Affiliation(s)
- Rcf Sinclair
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - M Navidi
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - S M Griffin
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - K Sumpter
- Freeman Hospital , Newcastle-upon-Tyne , UK
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Al-Momani H, Perry A, Stewart CJ, Jones R, Krishnan A, Robertson AG, Bourke S, Doe S, Cummings SP, Anderson A, Forrest T, Griffin SM, Brodlie M, Pearson J, Ward C. Microbiological profiles of sputum and gastric juice aspirates in Cystic Fibrosis patients. Sci Rep 2016; 6:26985. [PMID: 27245316 PMCID: PMC4887896 DOI: 10.1038/srep26985] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 02/16/2016] [Accepted: 05/11/2016] [Indexed: 02/08/2023] Open
Abstract
Gastro-Oesophageal Reflux (GOR) is a key problem in Cystic Fibrosis (CF), but the relationship between lung and gastric microbiomes is not well understood. We hypothesised that CF gastric and lung microbiomes are related. Gastric and sputum cultures were obtained from fifteen CF patients receiving percutaneous endoscopic gastrostomy feeding. Non-CF gastric juice data was obtained through endoscopy from 14 patients without lung disease. Bacterial and fungal isolates were identified by culture. Molecular bacterial profiling used next generation sequencing (NGS) of the 16S rRNA gene. Cultures grew bacteria and/or fungi in all CF gastric juice and sputa and in 9/14 non-CF gastric juices. Pseudomonas aeruginosa(Pa) was present in CF sputum in 11 patients, 4 had identical Pa strains in the stomach. NGS data from non-CF gastric juice samples were significantly more diverse compared to CF samples. NGS showed CF gastric juice had markedly lower abundance of normal gut bacteria; Bacteroides and Faecalibacterium, but increased Pseudomonas compared with non-CF. Multivariate partial least squares discriminant analysis demonstrated similar bacterial profiles of CF sputum and gastric juice samples, which were distinct from non-CF gastric juice. We provide novel evidence suggesting the existence of an aerodigestive microbiome in CF, which may have clinical relevance.
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Affiliation(s)
- H Al-Momani
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - A Perry
- Department of Microbiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
| | - C J Stewart
- Northumbria University, Ellison Place, Newcastle-upon-Tyne NE1 8ST, UK
| | - R Jones
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - A Krishnan
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - A G Robertson
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - S Bourke
- Adult Cystic Fibrosis Centre and Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S Doe
- Adult Cystic Fibrosis Centre and Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S P Cummings
- School of Science and Engineering, Teesside University, Middlesbrough, TS1 3BA, UK
| | - A Anderson
- Adult Cystic Fibrosis Centre and Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - T Forrest
- Adult Cystic Fibrosis Centre and Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S M Griffin
- Adult Cystic Fibrosis Centre and Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - M Brodlie
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - J Pearson
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
| | - C Ward
- Institutes of Cellular Medicine and Cell &Molecular Biosciences, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne. NE2 4HH, UK
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Dent B, Griffin SM, Jones R, Wahed S, Immanuel A, Hayes N. Management and outcomes of anastomotic leaks after oesophagectomy. Br J Surg 2016; 103:1033-8. [PMID: 27146631 DOI: 10.1002/bjs.10175] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/02/2015] [Accepted: 02/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality. METHODS All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database. RESULTS A total of 390 oesophagectomies were performed (median age 65 (range 32-81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52-80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15-159) days; none of these patients died. CONCLUSION Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.
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Affiliation(s)
- B Dent
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - R Jones
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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McNair AGK, MacKichan F, Donovan JL, Brookes ST, Avery KNL, Griffin SM, Crosby T, Blazeby JM. What surgeons tell patients and what patients want to know before major cancer surgery: a qualitative study. BMC Cancer 2016; 16:258. [PMID: 27036216 PMCID: PMC4815149 DOI: 10.1186/s12885-016-2292-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The information surgeons impart to patients and information patients want about surgery for cancer is important but rarely examined. This study explored information provided by surgeons and patient preferences for information in consultations in which surgery for oesophageal cancer surgery was discussed. METHODS Pre-operation consultations in which oesophagectomy was discussed were studied in three United Kingdom hospitals and patients were subsequently interviewed. Consultations and interviews were audio-recorded, transcribed in full and anonymized. Interviews elicited views about the information provided by surgeons and patients' preferences for information. Thematic analysis of consultation-interview pairs was used to investigate similarities and differences in the information provided by surgeons and desired by patients. RESULTS Fifty two audio-recordings from 31 patients and 7 surgeons were obtained (25 consultations and 27 patient interviews). Six consultations were not recorded because of equipment failure and four patients declined an interview. Surgeons all provided consistent, extensive information on technical operative details and in-hospital surgical risks. Consultations rarely included discussion of the longer-term outcomes of surgery. Whilst patients accepted that information about surgery and risks was necessary, they really wanted details about long-term issues including recovery, impact on quality of life and survival. CONCLUSIONS This study demonstrated a need for surgeons to provide information of importance to patients concerning the longer term outcomes of surgery. It is proposed that "core information sets" are developed, based on surgeons' and patients' views, to use as a minimum in consultations to initiate discussion and meet information needs prior to cancer surgery.
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Affiliation(s)
- Angus G. K. McNair
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
- />Severn School of Surgery, Deanery House, Unit D, Vantage Office Park, Old Gloucester Road, Hambrook, Bristol, BS16 1GW UK
| | - F MacKichan
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - J. L. Donovan
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - S. T. Brookes
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - K. N. L. Avery
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - S. M. Griffin
- />Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - T. Crosby
- />Department of Oncology, Velindre Hospital, Whitchurch, Cardiff, CF14 2TL UK
| | - J. M. Blazeby
- />School of Social & Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
- />University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8HW UK
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Lagarde SM, Phillips AW, Navidi M, Disep B, Immanuel A, Griffin SM. The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence. Br J Cancer 2015; 113:1427-33. [PMID: 26554656 PMCID: PMC4815887 DOI: 10.1038/bjc.2015.354] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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: 08/08/2015] [Revised: 09/07/2015] [Accepted: 09/14/2015] [Indexed: 12/16/2022] Open
Abstract
Background: In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy. Methods: Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes. Results: A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis. Conclusions: In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.
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Affiliation(s)
- S M Lagarde
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
| | - A W Phillips
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
| | - M Navidi
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
| | - B Disep
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-Upon-Tyne NE1 4LP, UK
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Abstract
Barrett's metaplasia is a well-recognized risk factor for esophageal adenocarcinoma. It is believed to develop in response to the injurious effects of gastroesophageal reflux. Following subtotal esophagectomy and reconstruction with a gastric conduit, many patients experience profound reflux into the remnant esophagus. Barrett's-like epithelium has been described in these patients, and they have been identified as a potential human model in which to study the early events in the development of metaplasia. This phenomenon also raises clinical concerns about the long-term fate of the esophageal remnant following surgery and the potential for further malignant change. This systematic review summarizes the literature on the prevalence and timing of Barrett's metaplasia occurring after esophagectomy, reviews the evidence regarding risk factors and malignant progression in such patients, and considers the implications for clinical practice.
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Affiliation(s)
- L J Dunn
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, Carli F, Demartines N, Griffin SM, Lassen K, Fearon KCF, Ljungqvist O, Lobo DN, Revhaug A. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 2014; 101:1209-29. [PMID: 25047143 DOI: 10.1002/bjs.9582] [Citation(s) in RCA: 434] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/20/2014] [Accepted: 05/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.
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Affiliation(s)
- K Mortensen
- Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | | | | | | | | | | | | | | | | | - K C F Fearon
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, UK
| | - O Ljungqvist
- Department of Surgery, Örebro University Hospital, Örebro and Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - A Revhaug
- Department of Gastrointestinal and Hepatopancreaticobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
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Blazeby JM, Strong S, Donovan JL, Wilson C, Hollingworth W, Crosby T, Nicklin J, Falk SJ, Barham CP, Hollowood AD, Streets CG, Titcomb D, Krysztopik R, Griffin SM, Brookes ST. Feasibility RCT of definitive chemoradiotherapy or chemotherapy and surgery for oesophageal squamous cell cancer. Br J Cancer 2014; 111:234-40. [PMID: 24921919 PMCID: PMC4102950 DOI: 10.1038/bjc.2014.313] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 01/26/2014] [Revised: 04/25/2014] [Accepted: 05/12/2014] [Indexed: 01/26/2023] Open
Abstract
Background: The optimal treatment for localised oesophageal squamous cell carcinoma (SCC) is uncertain. We assessed the feasibility of an RCT comparing neoadjuvant treatment and surgery with definitive chemoradiotherapy. Methods: A feasibility RCT in three centres examined incident patients and reasons for ineligibility using multi-disciplinary team meeting records. Eligible patients were offered participation in the RCT with integrated qualitative research involving audio-recorded recruitment appointments and interviews with patients to inform recruitment training for staff. Results: Of 375 patients with oesophageal SCC, 42 (11.2%) were eligible. Reasons for eligibility varied between centres, with significantly differing proportions of patients excluded because of total tumour length (P=0.002). Analyses of audio-recordings and patient interviews showed that recruiters had challenges articulating the trial design in simple terms, balancing treatment arms and explaining the need for randomisation. Before analyses of the qualitative data and recruiter training no patients were randomised. Following training in one centre 5 of 16 eligible patients were randomised. Conclusions: An RCT of surgical vs non-surgical treatment for SCC of the oesophagus is not feasible in the UK alone because of the low number of incident eligible patients. A trial comparing diverse treatment approaches may be possible with investment to support the recruitment process.
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Affiliation(s)
- J M Blazeby
- 1] Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK [2] Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - S Strong
- 1] Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK [2] Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - J L Donovan
- Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
| | - C Wilson
- Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
| | - W Hollingworth
- Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
| | - T Crosby
- Velindre NHS Trust, Unit 2 Charnwood Court, Cardiff CF14 2TL, UK
| | - J Nicklin
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - S J Falk
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol BS8 2PS, UK
| | - C P Barham
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - A D Hollowood
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - C G Streets
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - D Titcomb
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - R Krysztopik
- 1] Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK [2] Royal United Hospital Bath, Bath, BA1 3NG, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
| | - S T Brookes
- Centre of Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
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Abstract
Darrien JH, Kasem H Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome. Ann R Coll Surg Engl 2013; 95: 552–556 doi 10.1308/003588413X13629960049315
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Affiliation(s)
- B Dent
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK.
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37
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Wahed S, Dent B, Jones R, Griffin SM. Spectrum of oesophageal perforations and their influence on management. Br J Surg 2013; 101:e156-62. [DOI: 10.1002/bjs.9338] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 01/23/2023]
Abstract
Abstract
Background
Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.
Methods
All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.
Results
There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days.
Conclusion
The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.
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Affiliation(s)
- S Wahed
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - B Dent
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - R Jones
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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Sultan J, Griffin SM, Di Franco F, Kirby JA, Shenton BK, Seal CJ, Davis P, Viswanath YKS, Preston SR, Hayes N. Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery. Br J Surg 2012; 99:346-55. [PMID: 22237467 PMCID: PMC3625735 DOI: 10.1002/bjs.7799] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [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] [Accepted: 10/05/2011] [Indexed: 12/31/2022]
Abstract
Background Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery. Methods Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation. Results Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204). Conclusion Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- J Sultan
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Robertson AGN, Krishnan A, Ward C, Pearson JP, Small T, Corris PA, Dark JH, Karat D, Shenfine J, Griffin SM. Anti-reflux surgery in lung transplant recipients: outcomes and effects on quality of life. Eur Respir J 2011; 39:691-7. [PMID: 21778169 DOI: 10.1183/09031936.00061811] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fundoplication may improve survival after lung transplantation. Little is known about the effects of fundoplication on quality of life in these patients. The aim of this study was to assess the safety of fundoplication in lung transplant recipients and its effects on quality of life. Between June 1, 2008 and December 31, 2010, a prospective study of lung transplant recipients undergoing fundoplication was undertaken. Quality of life was assessed before and after surgery. Body mass index (BMI) and pulmonary function were followed up. 16 patients, mean ± sd age 38 ± 11.9 yrs, underwent laparoscopic Nissen fundoplication. There was no peri-operative mortality or major complications. Mean ± SD hospital stay was 2.6 ± 0.9 days. 15 out of 16 patients were satisfied with the results of surgery post fundoplication. There was a significant improvement in reflux symptom index and DeMeester questionnaires and gastrointestinal quality of life index scores at 6 months. Mean BMI decreased significantly after fundoplication (p = 0.01). Patients operated on for deteriorating lung function had a statistically significant decrease in the rate of lung function decline after fundoplication (p = 0.008). Laparoscopic fundoplication is safe in selected lung transplant recipients. Patient benefit is suggested by improved symptoms and satisfaction. This procedure is acceptable, improves quality of life and may reduce deterioration of lung function.
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Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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41
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Webb M, Griffin SM, Shenfine J. A pilot study of fully covered self-expandable metal stents prior to neoadjuvant therapy for locally advanced esophageal cancer. Dis Esophagus 2011; 24:48. [PMID: 20545982 DOI: 10.1111/j.1442-2050.2010.01082.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Clark E, Krishnan A, Dunn LJ, Robertson AGN, Griffin SM. Stage-for-stage comparison of definitive chemoradiotherapy, surgery alone and neoadjuvant chemotherapy for oesophageal carcinoma (Br J Surg 2009; 96: 1300–1307). Br J Surg 2010; 97:792-3; author reply 793. [DOI: 10.1002/bjs.7069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- E Clark
- Northern Oesophagogastric Cancer Unit, Newcastle upon Tyne, UK
| | - A Krishnan
- Northern Oesophagogastric Cancer Unit, Newcastle upon Tyne, UK
| | - L J Dunn
- Northern Oesophagogastric Cancer Unit, Newcastle upon Tyne, UK
| | - A G N Robertson
- Northern Oesophagogastric Cancer Unit, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Cancer Unit, Newcastle upon Tyne, UK
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Krishnan A, Robertson AGN, Dunn LJ, Robinson S, Hayes N, Griffin SM. Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents (Br J Surg 2009; 96: 887-891). Br J Surg 2010; 97:294; author reply 294-5. [PMID: 20069602 DOI: 10.1002/bjs.6973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
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Robertson AGN, Dunn LJ, Immanuel A, Griffin SM. An unusual presentation of herpes simplex esophagitis: a nonhealing "peptic" ulcer. Endoscopy 2009; 41 Suppl 2:E213. [PMID: 19757359 DOI: 10.1055/s-0029-1214687] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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Robertson AGN, Ward C, Pearson JP, Small T, Lordan J, Fisher AJ, Bredenoord AJ, Dark J, Griffin SM, Corris PA. Longitudinal changes in gastro-oesophageal reflux from 3 months to 6 months after lung transplantation. Thorax 2009; 64:1005-7. [DOI: 10.1136/thx.2009.117879] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Griffin SM, Shenfine J. Authors' reply: Spontaneous rupture of the oesophagus ( Br J Surg 2008; 95: 1115–1120). Br J Surg 2009. [DOI: 10.1002/bjs.6758] [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] [Indexed: 11/09/2022]
Affiliation(s)
- S M Griffin
- Department of Upper Gastrointestinal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - J Shenfine
- Department of Upper Gastrointestinal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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Robertson AGN, Griffin SM, Murphy DM, Pearson JP, Forrest IA, Dark JH, Corris PA, Ward C. Targeting allograft injury and inflammation in the management of post-lung transplant bronchiolitis obliterans syndrome. Am J Transplant 2009; 9:1272-8. [PMID: 19459806 DOI: 10.1111/j.1600-6143.2009.02648.x] [Citation(s) in RCA: 23] [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] [Indexed: 01/25/2023]
Abstract
Chronic allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is the major cause of morbidity and mortality in human lung transplant recipients. While alloimmunity has a definite role, there is increasing interest in overall allograft injury and subsequent inflammation and remodeling. This review deals with nonalloimmune factors that may potentiate alloimmune injury. We discuss infection and reflux/aspiration as examples of allograft injury, which may lead to chronic loss of graft function and BOS. Surgical and nonsurgical treatments aimed at preventing these insults and improving survival are considered. The need for further evidence, including randomized-controlled trials, to evaluate the role of medical and surgical therapies is emphasized by the current literature.
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Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle University, Newcastle, UK
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48
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Robertson AGN, Griffin SM, Murphy DM, Pearson JP, Forrest IA, Dark JH, Corris PA, Ward C. Targeting allograft injury and inflammation in the management of post-lung transplant bronchiolitis obliterans syndrome. Am J Transplant 2009. [PMID: 19459806 DOI: 10.1111/j.1600-7143.2009.02648.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Chronic allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is the major cause of morbidity and mortality in human lung transplant recipients. While alloimmunity has a definite role, there is increasing interest in overall allograft injury and subsequent inflammation and remodeling. This review deals with nonalloimmune factors that may potentiate alloimmune injury. We discuss infection and reflux/aspiration as examples of allograft injury, which may lead to chronic loss of graft function and BOS. Surgical and nonsurgical treatments aimed at preventing these insults and improving survival are considered. The need for further evidence, including randomized-controlled trials, to evaluate the role of medical and surgical therapies is emphasized by the current literature.
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Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle University, Newcastle, UK
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Amonkar SJ, Irving M, Wayman J, Sriram T, Griffin SM, Nicoll JJ, Raimes SA. The changing use of palliative chemotherapy for recurrent esophagogastric cancer: a single center retrospective 15-year review. J Gastrointest Cancer 2009; 39:51-7. [PMID: 19238591 DOI: 10.1007/s12029-009-9051-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 02/05/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative chemotherapy is often recommended in the treatment of recurrent esophagogastric (EG) cancer with limited evidence of its benefit. This study aims to define the current practice and benefit of this treatment. METHODS Retrospective analysis of patients who developed EG cancer recurrence between 1991 and 2006 following surgery with curative intent. RESULTS There were 336 recurrences. Median time to disease recurrence was 13.4 months (range 1.3-118). Survival after recurrence ranged from 0-93.2 months (six patients are currently alive). A significant increase in the use of chemotherapy was observed rising from 10% prior to 1999 (n = 100) to 23% (n = 236) after 1999. The median survival for patients receiving chemotherapy (n = 64) was 10.6 months (range 1.5-75.7), patients undergoing nonchemotherapy palliative intervention (n = 142) median survival was 2.85 months (range 0-93.2), and for patients having no active intervention (n = 130), median survival was 1.3 months (range 0-16.2). Median duration of chemotherapy was 3.1 months (range 0.5-9.2). Median survival for these patients after chemotherapy treatment was 6.6 months (range 0.4-73.5). Twenty-eight patients (44%) experienced side effects of chemotherapy. Ten cases required treatment to be modified or stopped and two patients died during chemotherapy. CONCLUSION There has been a significant increase in the use of palliative chemotherapy for recurrent EG cancer. While survival appears improved, a substantial proportion of this time was spent receiving chemotherapy with many patients experiencing significant comorbidity. Further studies assessing both quality and quantity of life are required to fully evaluate the use of palliative chemotherapy and to identify patients most likely to benefit.
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Affiliation(s)
- S J Amonkar
- Northern Oesophago-Gastric Cancer Unit, Newcastle upon Tyne & Carlisle, UK
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Abstract
BACKGROUND The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre. METHODS Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy. RESULTS The median time to diagnosis was 24 (range 4-604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Ttube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention. CONCLUSION Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.
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Affiliation(s)
- S M Griffin
- Department of Upper Gastrointestinal Surgery, Northern Oesophago-gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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