Postoperative Complications After Esophagectomy for Adenocarcinoma of the Esophagus Are Related to Timing of Death Due to Recurrence

International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA)

BACKGROUND

Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy.

METHOD

The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit.

RESULTS

Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001).

CONCLUSIONS

This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.

Impact of the Age-adjusted Charlson comorbidity index on the short- and long-term outcomes of patients undergoing curative gastrectomy for gastric cancer

Background: The aim of this study was to determine whether or not the short- and long-term outcomes were affected by the age-adjusted Charlson comorbidity index (ACCI) in patients who underwent curative resection for gastric cancer.

Methods: The patients were retrospectively selected from among the medical records of consecutive patients who underwent curative gastrectomy with nodal dissection for gastric cancer at Yokohama City University and Kanagawa Cancer Center from January 2000 to August 2015.

Results: A total of 2254 patients were eligible for inclusion in the present study. One thousand six hundred fifty-six patients had an ACCI of <6 points (ACCI low group), while 598 had a score of ≥6 points (ACCI high group). The median age (p<0.001) and American Society of Anesthesiologists physical status (ASA-PS) score (p<0.001) of the ACCI high group were higher in comparison to the ACCI low group. The incidence of surgical complications in the ACCI high group was significantly higher than that in the ACCI low group (12.0% vs. 7.2%, p<0.001). Univariate and multivariate analyses demonstrated that an ACCI high classification was a significant risk factor for postoperative complications. In addition, the 5-year OS rates of the ACCI low and ACCI high groups were 85.4% and 74.1%, respectively. The difference was statistically significant (p<0.001). The univariate and multivariate analyses demonstrated that an ACCI high classification was a significant prognostic factor for OS.

Conclusions: Our results support that a high ACCI value is an independent risk factor for the short- and long-term outcomes of patients with gastric cancer. To improve the survival of patients with gastric cancer, it is necessary to carefully plan the perioperative care and the surgical strategy according to the ACCI.

Pre-operative biliary drainage is associated with shortened survival time in patients with cholangiocarcinoma

BACKGROUND AND OBJECTIVE

Although pre-operative biliary drainage (PBD) is frequently performed in patients with cholangiocarcinoma (CCA), its impact on patient survival is unclear. Our aim was to evaluate the impact of PBD on overall survival of patients with extra-hepatic CCA.

METHODS

This was a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients who underwent biliary drainage within 3 months prior to and/or after diagnosis of CCA were included in the PBD cohort. Patients who did not receive biliary drainage were included in the non-PBD cohort. Cox proportional hazard regression was used to determine independent predictors of survival.

RESULTS

Of 3862 patients with extra-hepatic CCA, 433 (11.2%) underwent curative surgical resection, with a median survival of 14 months (95% confidence interval [95% CI], 10-21 months) in the PBD cohort (n = 126) vs 31 months (95% CI, 26-39 months) in the non-PBD cohort (n = 307) (P < 0.001), during the median follow-up duration for the surgical cohort of 26 months (range, 1-60 months). Among the 433 patients, 126 (29.1%) underwent PBD and had significantly higher Charlson comorbidity index and advanced SEER stage than those without PBD before surgery. On multivariable analysis in patients who underwent curative surgical resection, after adjusting patient demographics, tumor characteristics, Charlson comorbidity index, radiotherapy and chemotherapy, PBD was significantly associated with shortened survival time (hazard ratio, 2.35; 95% CI, 1.34-4.10; P = 0.003).

CONCLUSIONS

PBD appears negative impact on long-term survival in patients with potentially resectable CCA and should be avoided if possible.

Effects of improving outcomes after esophagectomy on the short- and long-term: a review of literature

An esophagectomy is still correlated with a high morbidity rate, despite advances made in minimally invasive surgery, enhanced recovery after surgery (ERAS) and centralization of this type of surgery. The short-term benefits are clearly described for esophageal cancer surgery patients, however, the long-term effects are yet to be determined. In colorectal cancer, the association between complications, especially anastomotic leakage, shows detrimental effects on long-term survival and cancer recurrence. In esophageal cancer surgery, current evidence is scarce and the described results are conflicting. Optimization of perioperative care by introduction of minimally invasive surgery, ERAS programs and patient prehabilitation is promising and shows a clear effect on short-term outcomes. Potentially, this may also result in better outcomes on the long-term, although current evidence is insufficient to infer definite conclusions. Reduction of anastomotic leakage seems important to reduce risk of cancer recurrence and improve long-term outcome.

Postoperative Pneumonia is Associated with Long-Term Oncologic Outcomes of Definitive Chemoradiotherapy Followed by Salvage Esophagectomy for Esophageal Cancer

BACKGROUND OR PURPOSE

As we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART).

METHODS

Ninety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy.

RESULTS

Patients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24 months vs neoadjuvant, 43 months, p = 0.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (p < 0.001) and DFS (p = 0.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS.

DISCUSSION

The present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.

[Intrathoracic anastomotic leakage following esophageal and cardial resection : Definition and validation of a new severity grading classification]

BACKGROUND

Anastomotic leakage is still the most frequent cause of postoperative mortality following esophageal and cardial surgery. The German Advanced Surgical Study Group recommended that endoscopy should be the first diagnostic method if leakage is suspected. The German Surgical Endoscopy Association developed and validated a definition and severity classification of anastomotic leakage following esophageal and cardial resection.

MATERIAL AND METHODS

In 2010 the international study group on insufficiency published a definition and severity grading of anastomotic leakage following anterior resection of the rectum, which was validated in 2013. The severity of anastomotic leakage should be graded according to the impact on clinical management: type I requires only conservative management, type II requires interventional radiological or endoscopic treatment and type III requires surgical revision. In contrast to the rectal classification type III is divided into a category without (type IIIa) or with (type IIIb) conduit resection and diversion. The validation was carried out on a 10-year collective from the university hospitals in Heidelberg and Tübingen.

RESULTS

From 2006-2015 all 92 patients who developed an anastomotic leakage following esophageal and cardial resection were enrolled in the study. We found a significant increase in the length of stay in the intensive care unit (ICU) with increasing classification type (p < 0.0143). Furthermore, there was a significant correlation with the general classification of postoperative complications according to Clavien-Dindo as well as with mortality (p < 0.001).

DISCUSSION

Standardized parameters are the prerequisite to be able to compare the results between hospitals and studies. The validation of the suggested classification shows that the differentiation between the groups is substantiated by the correlation to the length of ICU stay, Clavien-Dindo and mortality and will therefore contribute to a better comparability of data on leakage following esophageal resection in the future.

Technical feasibility and oncologic safety of diagnostic endoscopic resection for superficial esophageal cancer

BACKGROUND AND AIMS

Active use of endoscopic resection (ER) for cM3-SM2 esophageal cancer may enable sufficient extent of esophageal resection and help determine the need for lymph node dissection based on histopathologic findings. However, ER preceding esophagectomy may have an adverse impact on outcomes. This study was designed to determine the technical feasibility and oncologic safety of diagnostic ER.

METHODS

A single-institution retrospective cohort study was performed between July 2008 and June 2014. During this period, 135 consecutive patients with clinical T1a-M3N0M0, T1b-SM1N0M0, and T1b-SM2N0M0 primary esophageal cancer were referred to our division. Eight patients who underwent chemoradiotherapy as primary treatment were excluded because of inadequate pathologic findings. Based on oncologic and physical factors, we categorized the remaining 127 patients into 2 groups: primary esophagectomy (n = 54) and primary ER (n = 73).

RESULTS

In all 127 patients, the 3-year overall survival (OS) and disease-free survival (DFS) rates were 95.7% and 87.6%, respectively. No adverse event requiring surgical intervention was observed after ER. Diagnostic ER had no negative impact on surgical outcomes, DFS, and OS after esophagectomy. Fourteen patients (19.2%) of those who received primary ER underwent curative resection, whereas 11 (20.4%) who had pT1a disease, no lymphovascular invasion, and no pathologic lymph node metastasis underwent primary esophagectomy.

CONCLUSIONS

Diagnostic ER for cM3-SM2 esophageal cancer with or without subsequent esophagectomy was feasible and safe, not only from a surgical perspective but also an oncologic perspective. Approximately 20% of cM3-SM2N0M0 patients can potentially avoid undergoing additional treatment including esophagectomy using diagnostic ER.

Diagnosis, assessment, and management of surgical complications following esophagectomy

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

The Negative Survival Impact of Infectious Complications After Surgery is Canceled Out by the Response of Neoadjuvant Chemotherapy in Patients with Esophageal Cancer

BACKGROUND

This study was designed to investigate whether postoperative infectious complications (ICs) are a risk factor for the prognosis in esophageal cancer patients who receive neoadjuvant chemotherapy by stratifying the response to neoadjuvant chemotherapy.

METHODS

The present study retrospectively examined patients who received neoadjuvant chemotherapy followed by esophagectomy between January 2011 and September 2015. Risk factors for overall survival (OS) were examined by Cox proportional hazard analyses. Pathological responders to neoadjuvant chemotherapy were defined as those with a tumor disappearance of more than one-third of the initial tumor. Postoperative ICs were defined using the Clavien-Dindo classification.

RESULTS

Of the 111 patients examined, 45 (40.5%) developed postoperative ICs. A pathological response to neoadjuvant chemotherapy was observed in 54 (48.6%) patients. The multivariate analysis demonstrated that postoperative ICs were a significant independent risk factor for the OS (hazard ratio [HR] 2.359; 95% confidence interval [CI] 1.057-5.263, p = 0.036). In the subset analysis, postoperative ICs were a marginally significant independent risk factor for OS in the nonresponders (HR 2.862; 95% CI 0.942-8.696, p = 0.063) but not in the responders (HR 0.867; 95% CI 0.122-6.153, p = 0.886).

CONCLUSIONS

These results suggested that the negative survival impact of postoperative ICs can be canceled out in esophageal cancer patients who respond to neoadjuvant chemotherapy.

Recurrence following curative intended surgery for an adenocarcinoma in the gastroesophageal junction: a retrospective study

Recurrence following a resection for an adenocarcinoma of the gastroesophageal junction leads to reduced long-term survival. This study aims to identify risk factors associated with recurrence, recurrence localization, time to recurrence, and long-term survival. All patients undergoing curative intended resection for an adenocarcinoma of the gastroesophageal junction at Rigshospitalet between June 2003 and December 2011 were identified through a prospectively maintained nationwide database and enrolled in this study. Only histologically verified recurrence was considered eligible. Recurrence within six months, microscopically incomplete resection margins, and death within eight weeks were excluded. A total of 348 patients were included in this study. Biopsy-verified recurrence occurred in 120 patients (34.5%), with 32 local (9.2%), and 88 distant (25.3%) recurrences. Lymph node metastases was associated with an increased risk of recurrence (hazard ratio; [95% confidence interval]: HR = 2.7; [1.7-4.3], P < 0.001). Median time to local versus distant recurrence was 18 months (interquartile range (IQR): 9-37 months) versus 17 months (IQR: 11-27 months), P = 0.96, respectively. A trend toward local recurrence was identified if patients had anastomotic leakage (HR = 2.64; [0.89-7.86], P = 0.08). Survival was inversely associated with recurrence, but a survival comparison between local and distant recurrences showed no significant difference: median survival time was 28 months (IQR: 17-43 months) versus 24 months (IQR: 16-36 months), P = 0.45, respectively. A trend toward local recurrence was seen if the patient had an anastomotic leakage event. However, no factors were associated with site-specific recurrence (local vs. distant).

Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer

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 &lt; 0·010). Measurements were also significantly different at each time point (P &lt; 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 &lt; 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.

Intrathoracic versus cervical anastomosis and predictors of anastomotic leakage after oesophagectomy for cancer

Background

Studies comparing the anastomotic leak rate in patients with an intrathoracic versus a cervical anastomosis after oesophagectomy are equivocal. The aim of this study was to compare clinical outcome after oesophagectomy in patients with an intrathoracic or cervical anastomosis, and to identify predictors of anastomotic leakage in a nationwide audit.

Methods

Between January 2011 and December 2015, all consecutive patients who underwent oesophagectomy for cancer were identified from the Dutch Upper Gastrointestinal Cancer Audit. For the comparison between an intrathoracic and cervical anastomosis, propensity score matching was used to adjust for potential confounders. Multivariable logistic regression modelling with backward stepwise selection was used to determine independent predictors of anastomotic leakage.

Results

Some 3348 patients were included. After propensity score matching, 654 patients were included in both the cervical and intrathoracic anastomosis groups. An intrathoracic anastomosis was associated with a lower leak rate than a cervical anastomosis (17·0 versus 21·9 per cent; P = 0·025). The percentage of patients with recurrent nerve paresis was also lower (0·6 versus 7·0 per cent; P < 0·001) and an intrathoracic anastomosis was associated with a shorter median hospital stay (12 versus 14 days; P = 0·001). Multivariable analysis revealed that ASA fitness grade III or higher, chronic obstructive pulmonary disease, cardiac arrhythmia, diabetes mellitus and proximal oesophageal tumours were independent predictors of anastomotic leakage.

Conclusion

An intrathoracic oesophagogastric anastomosis was associated with a lower anastomotic leak rate, lower rate of recurrent nerve paresis and a shorter hospital stay. Risk factors for anastomotic leak were co‐morbidities and proximal tumours.

Lower leak rates after intrathoracic anastomosis

Significant decrease of mortality due to anastomotic leaks following esophageal resection: management makes the difference

PURPOSE

Anastomotic leakage is the most frequent cause of postoperative mortality following esophageal surgery. However, no gold standard for diagnosing and managing leakage has been established. Continuous clinical judgment is extremely important; therefore, to optimize the management of leakage, we established a special group for decision-making in cases of suspected leakage in the early postoperative period.

METHODS

Between January 2010 and December 2016, 234 consecutive patients underwent elective esophageal resection with a thoracoabdominal incision. In 2014, we established a group consisting of a surgeon, surgical endoscopist, and anesthesiologist for decision-making in cases of suspected leakage. They discussed emerging problems and decided on further diagnostics or therapy. The data were documented prospectively and compared to the years prior to 2014.

RESULTS

Two hundred and thirty-four consecutive patients were enrolled in the study, 110 in the years 2010-2013 (group A), and 124 in the years 2014-2016 (group B). Neither patients' characteristics nor the rate of anastomotic leakage differed significantly between the two study groups. The hospital mortality rate was 10% (11 patients) in group A and 4.8% (six patients) in group B. Most interestingly, mortality due to anastomotic leakage was 35% in group A (9/26), whereas it decreased significantly to 6.5% (2/31 patients) (P < 0.001) in group B.

CONCLUSIONS

Our data clearly demonstrated that optimizing the management of anastomotic leakage by making team decisions can lead to a significant decrease in mortality.

High serum lactate as an adjunct in the early prediction of anastomotic leak following oesophagectomy

BACKGROUND

Anastomotic leak (AL) following oesophagectomy carries a high mortality and morbidity. Early detection and intervention is required for a successful outcome. We have examined the role of a high postoperative serum lactate in predicting which patients are at risk of developing an anastomotic leak(AL).

MATERIALS AND METHODS

All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database. Medical records were reviewed to identify the highest serum lactate recorded from blood gas analysis over each 24hr post-operative period. Patients who underwent transhiatal and left thoraco-abdominal oesophagectomies were excluded. Patients who developed a chyle leak were excluded.

RESULTS

Of a total of 136 oesophagectomies included for analysis, 18 developed an AL (13.2%). Of these patients, 10 underwent thoracoscopic oesophageal mobilization with cervical anastomosis and the rest an Ivor Lewis procedure. Predictive factors for AL included neoadjuvant chemotherapy (15/18 83.3% vs 55/118 46.6% p = 0.0046) and number of positive lymph nodes (mean 4.2 vs control mean 2.3 p = 0.045). Overall net fluid balance was comparable between the 2 groups, although AL patients received slightly more fluid on Day 3. High lactate levels on days 1-3 were associated with an AL. Using a Day 2 lactate of 1.7 mmol/L, the sensitivity of predicting AL was 72% and specificity 88%. The mean lag time using existing diagnostic modalities was 7.9 days.

CONCLUSION

A serum lactate of >1.7 mmol/l on day 2 should raise the possibility of a potential AL. Such patients should be selected for more intensive monitoring, optimization and selective gastroscopy.

Impact of postoperative complications on the colorectal cancer survival and recurrence: analyses of pooled individual patients' data from three large phase III randomized trials

This study assessed the impact of postoperative complications on the colorectal cancer survival and recurrence after curative surgery using pooled individual patients’ data from three large phase III randomized trials. In total, 5530 patients were included in this study. The patients were classified as those with postoperative complications (C group) and those without postoperative complications (NC group). The risk factors for the overall survival (OS) and the disease‐free survival (DFS) were analyzed. Postoperative complications were found in 861 (15.6%) of the 5530 patients. The OS and DFS rates at 5 years after surgery were 68.9% and 74.8%, respectively, in the C group and 75.8% and 82.2%, respectively, in the NC group, values that were significantly different between the two groups (P < 0.001). The multivariate analysis demonstrated that postoperative complications were a significant independent risk factor for the OS and DFS. Postoperative complications can worsen the colorectal cancer survival and risk of recurrence. Surgical morbidity must be considered as a stratification factor in future phase III trials evaluating the effects of adjuvant chemotherapy on colorectal cancer.

Prognostic Significance of Postoperative Complications After Curative Resection for Patients With Esophageal Squamous Cell Carcinoma

OBJECTIVE

The objective of this study was to elucidate the impact of postoperative complications on long-term survival after curative resection for esophageal squamous cell carcinoma.

BACKGROUND

The relation between postoperative complications and long-term survival after curative surgery for esophageal squamous cell carcinoma is controversial; thus, this issue should be resolved with a large-scale, well-designed study.

METHODS

Clinicopathological features and survival of 580 consecutive patients who received curative resection for esophageal squamous cell carcinoma were investigated according to the development of postoperative pulmonary complications and anastomotic leakage.

RESULTS

The 5-year survival rates of patients with pStage 0, I, and II disease with postoperative complications (n = 116) were significantly poorer than those of patients without postoperative complications (n = 288) (overall 69.6% vs 46.9%, P < 0.0001; disease-specific; 76.7% vs 58.9%, P < 0.0022), whereas no differences were found in patients with pStage III and IV disease (n = 176). In the univariate and multivariate analyses for disease-specific survival, pT3, pT4, pN positivity, and development of postoperative complications were significant prognostic factors in all patients. Also, when the analysis was limited to the pStage 0, I, and II patients, development of postoperative complications, and pT3, pT4, and pN positivity, were found to be independent poor prognostic factors in multivariate analyses (hazard ratio: 1.56, 95% confidence interval, 1.01-2.41, P = 0.0476).

CONCLUSIONS

The development of postoperative complications is an independent disease-specific poor prognostic factor after curative resection for patients with less-advanced esophageal squamous cell carcinoma.

Prognostic impact of complications after resection of early stage hepatocellular carcinoma

BACKGROUND

Resection is the most effective treatment for HCC. However, postoperative morbidity is common and its impact on long-term oncological outcome remains unclear.

METHODS

Long-term outcomes of 774 patients who underwent curative resection for early stage HCC at Johns Hopkins Hospital and Toranomon Hospital were investigated after stratifying by the development of postoperative overall and infectious complications.

RESULTS

A minor or major postoperative complication developed in 281 and 65 patients, respectively, while postoperative mortality was 1.3% (n = 10). The 5-year cumulative recurrence and overall survival(OS) rates were 57.2% and 76.4%, respectively. Overall postoperative complications independently predicted worse OS in multivariable analysis (HR = 1.42, P = 0.021). Complication severity did not correlate with OS (P > 0.05). While infectious complications were not independent predictors of OS, the combination of blood transfusion and infectious complications led to significantly worse OS (66.3% vs. 44.9%, P = 0.008). Postoperative complications also correlated with increased recurrence risk, but only in patients with non-cirrhotic parenchyma (55.0% vs. 47.7%, P = 0.035) or non-viral hepatitis (55.6% vs. 44.4%, P = 0.002).

CONCLUSIONS

Post-operative morbidity independently predicted poor OS following hepatectomy for early stage HCC. A similar effect on recurrence was noted only in patients with favorable etiopathologic factors. Finally, the combination of peri-operative transfusion and subsequent infectious complications was associated with a synergistic negative effect on prognosis.

Diabetes mellitus and risk of anastomotic leakage after esophagectomy: a systematic review and meta-analysis

Diabetes mellitus has the probability to impair the anastomotic healing and cause postesophagectomy anastomotic leakages but previous studies showed controversial results. This review aims to summary the impact of diabetes mellitus on the risk of anastomotic leakage after esophagectomy. We searched the PubMed and EMBASE databases to recognize English articles that met our eligibility criteria. Odds ratio with 95% confidence interval serves as the appropriate summarized statistic. Sensitivity analysis, meta-regression analysis, and publication bias tests were also performed to perceive potential bias risks. Finally, 16 observational studies with 12359 surgical patients were included. An overall analysis identified that diabetes mellitus was significantly associated with the risk of anastomotic leakage after esophagectomy (odds ratio = 1.63; 95% confidence interval = 1.25-2.12; P < 0.001). Further subgroup analysis showed a significant impact of diabetes mellitus in surgical populations from the Europe and America (odds ratio = 1.42; 95% confidence interval = 1.22-1.65; P < 0.001) but not in the Asian populations (odds ratio = 2.27; 95% confidence interval = 0.86-6.05; P = 0.1). The robustness of these estimates was confirmed by meta-regression analysis and sensitivity analysis. No significant publication bias exists between studies. In conclusion, this systematic review demonstrates that diabetes mellitus can be a significant risk factor of anastomotic leakage for patients undergoing esophagectomy. Our findings need to be further confirmed and modified by more well-designed worldwide multivariable analyses in the future.

Routine Use of Contrast Swallow After Total Gastrectomy and Esophagectomy: Is it Justified?

BACKGROUND

After gastrectomy or esophagectomy, esophagogastrostomy and esophagojejunostomy are commonly used for reconstruction. Water-soluble contrast swallow is often used as a routine screening to exclude anastomotic leakage during the first postoperative week. In this retrospective study, the sensitivity and specificity of oral water-soluble contrast swallow for the detection of anastomotic leakage and its clinical symptoms were analysed.

MATERIAL/METHODS

Records of 104 consecutive total gastrectomies and distal esophagectomies were analysed. In all cases, upper gastrointestinal contrast swallow with the use of a water-soluble contrast agent was performed on the 5^th postoperative day. Extravasation of the contrast agent was defined as anastomotic leakage. When anastomotic insufficiency was suspected but no extravasation was present, a computed tomography (CT) scan and upper endoscopy were performed.

RESULTS

Oral contrast swallow detected 7 anastomotic leaks. Based on CT-scans and upper endoscopy, the true number of anastomotic leakage was 15. The findings of the oral contrast swallow were falsely positive in 4 and falsely negative in 12 patients, respectively. The sensitivity and specificity of the oral contrast swallow was 20% and 96%, respectively.

CONCLUSIONS

Routine radiological contrast swallow following total gastrectomy or distal esophagectomy cannot be recommended. When symptoms of anastomotic leakage are present, a CT-scan and endoscopy are currently the methods of choice.

Management and outcome of cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer

The aim of this study was to evaluate management strategies and related outcomes for cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer with gastric conduit reconstruction. Patients with esophageal cancer undergoing transthoracic esophagectomy with cervical anastomosis from October 2003 to December 2014 were identified from a prospectively acquired database. Management strategies and related outcomes among patients with anastomotic leakage confined to the neck were compared to patients with intrathoracic manifestation of anastomotic leakage. From a total of 286 patients, leakage of the cervical anastomosis occurred in 60 patients (21%) at a median time of 7 days after esophagectomy. Leakage was confined to the neck in 23 of 60 patients (38%), whereas 37 of 60 patients (62%) presented with intrathoracic spread. Leakages with intrathoracic manifestation were more frequently accompanied by a positive SIRS score compared to leakages confined to the neck (73% vs. 35%, respectively; P = 0.004). Drainage of the anastomotic leakage through the neck wound was effective in all of 23 patients (100%) with cervical manifestation. In patients with intrathoracic manifestation, mediastinal drainage through the neck was successful in 15 of 37 patients (41%), whereas 22 patients (59%) required an intervention through the thoracic cavity. Compared to patients with leakage confined to the neck, patients with intrathoracic manifestation showed prolonged intensive care unit (ICU) stay (median 6 vs. 2 days, respectively; P = 0.001), hospital stay (median 34 vs. 19 days, respectively; P < 0.001), and time to oral intake (32 vs. 23 days, respectively; P = 0.018). Intrathoracic manifestation of cervical anastomotic leakage occurs in more than half of patients with anastomotic leakage after transthoracic esophagectomy for cancer. A SIRS reaction should raise the suspicion of intrathoracic spread of leakage. Intrathoracic manifestation can be managed effectively by mediastinal drainage through the neck in 41% of patients, but a reintervention through the thoracic cavity is required in 59%. Intrathoracic manifestation of leakage results in prolonged ICU/hospital stay and delays time to oral intake compared with leakage confined to the neck.

An Institutional Experience of Introducing an Enhanced Recovery After Surgery (ERAS) Program for Pancreaticoduodenectomy

This study assessed whether our enhanced recovery after surgery (ERAS) program for pancreaticoduodenectomy (PD) is safe and feasible. The subjects included 109 consecutive patients who underwent PD between 2012 and 2014 at the Department of Gastrointestinal Surgery, Kanagawa Cancer Center. They received perioperative care according to the ERAS program. All data were retrieved retrospectively. Outcome measures included postoperative mortality, morbidity, hospitalization, and 30-day readmission rate. Our ERAS program included 12 elements (4 preoperative, 3 intraoperative, and 5 postoperative elements). Of the 109 patients studied, the overall incidence of morbidity was 51.4%, the incidence of mortality was 1.8%, and the incidence of readmission was 1.8%. The median postoperative hospital stay (23 days) was significantly shorter than the pre-ERAS value (29 days). Though 4 preoperative and 2 intraoperative elements were feasible, only 1 among 5 postoperative elements was applicable. Our ERAS program for PD has succeeded in shortening the postoperative hospital stay without increasing the risk of morbidity or mortality. The cutoff values of postoperative ERAS elements, however, were not feasible and should be reconsidered.

Cancer Recurrence After Esophagectomy: Impact of Postoperative Infection in Propensity-Matched Cohorts

BACKGROUND

Postoperative infection increases cancer recurrence and worsens survival in colorectal cancer, but the relationship for esophagogastric adenocarcinoma after esophagectomy is not well defined. We aimed to determine whether recurrence and survival after minimally invasive esophagectomy for esophagogastric adenocarcinoma were influenced by postoperative infection using propensity-matched analysis.

METHODS

We abstracted data for 810 patients (1997-2010) and defined exposure as at least 1 in-hospital or 30-day infectious complication (n = 206 [25%]). Using 29 pretreatment/intraoperative variables, patients were propensity-score matched (caliper = 0.05). Time to cancer recurrence and survival (Kaplan-Meier curves and the Breslow test), and associated factors (Cox regression with shared frailty) were assessed.

RESULTS

After propensity matching (n = 167 pairs), median bias across propensity-score variables was reduced from 12.9% (p < 0.001) to 4.4% (p = 1.000). Postoperative infection was not associated with rate (n = 60 versus 63; McNemar p = 0.736) or time to recurrence in those in whom disease recurred (median, 10.7 versus 11.1 months; Wilcoxon signed-rank p = 0.455) but was associated with shorter overall survival (n = 124 versus 102 deaths; median, 26 versus 41 months; Breslow p = 0.002). After adjusting for age, body mass index, neoadjuvant therapy, sex, comorbidity score, positive resection margins, pathologic stage, R0 resection, and recurrence, postoperative infection was associated with a 44% greater hazard for death (hazard ratio, 1.44; 95% confidence interval, 1.10-1.89).

CONCLUSIONS

In patients with esophagogastric adenocarcinoma, infections after esophagectomy were not associated with an increased rate or earlier time to recurrence when baseline characteristics associated with infection risk were balanced using propensity-score matching. Despite this, overall survival was shorter in patients with infectious complications. After adjusting for other important survival predictors, infections after esophagectomy continued to be independently associated with worse survival.

Extranodal extension of lymph node metastasis is a marker of poor prognosis in oesophageal cancer: a systematic review with meta-analysis

The extranodal extension (ENE) of nodal metastasis is the extension of neoplastic cells through the nodal capsule into the perinodal adipose tissue. This histological feature has recently been indicated as an important prognostic factor in different types of malignancies; in this manuscript, we aim at defining its role in the prognosis of oesophageal cancer with the tool of meta-analysis. Two independent authors searched SCOPUS and PubMed until 31 August 2015 without language restrictions. The studies with available data about prognostic parameters in subjects with oesophageal cancer, comparing patients with the presence of ENE (ENE+) versus only intranodal extension (ENE-), were considered as eligible. Data were summarised using risk ratios (RRs) for number of deaths/recurrences and HRs together with 95% CIs for time-dependent risk related to ENE+, adjusted for potential confounders. Fourteen studies were selected; they followed-up 1437 patients with oesophageal cancer for a median follow-up of 39.4 months. The presence of ENE was associated with a significantly increased risk of all-cause mortality (RR=1.33; 95% CI 1.18 to 1.50, p<0.0001, I2=49%; HR=2.72, 95% CI 2.03 to 3.64, p<0.0001, I2=0%), cancer-specific mortality (RR=1.35; 95% CI 1.14 to 1.59, p=0.001, I2=57%; HR=1.97, 95% CI 1.41 to 2.75, p<0.0001, I2=41%) and of risk of recurrence (RR=1.50, 95% CI 1.20 to 1.88, p<0.0001, I2=9%; HR=2.27, 95% CI 1.72 to 2.90, p<0.0001, I2=0%). On the basis of these results, in oesophageal cancer, ENE should be considered from the gross sampling to the pathology report, and in future oncological staging system.

Radiation to the Gastric Fundus Increases the Risk of Anastomotic Leakage After Esophagectomy

BACKGROUND

Concerns have been raised regarding the toxicity of neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer that could contribute to an increased risk of postoperative complications. The aim of this study was to determine the influence of the radiation dose to the gastric fundus on the risk of postoperative anastomotic leakage in patients undergoing nCRT followed by transthoracic esophagectomy.

METHODS

Between January 2012 and July 2015, 97 consecutive patients who underwent nCRT followed by transthoracic esophagectomy were included in this single-center cohort study. The gastric fundus was contoured on the pretreatment planning computed tomography. Within this contour, dose-volume histogram variables were calculated, and logistic regression analysis was used to determine their influence on the risk of anastomotic leakage.

RESULTS

In 25 of 97 patients (26%) anastomotic leakage occurred. The mean radiation dose to the gastric fundus was significantly higher in patients with than without leakage (median 35.6 Gy versus 24.9 Gy, respectively, p = 0.047). A mean dose more than versus less than 31.4 Gy was associated with leakage rates of 43% versus 15%, respectively. Adjusted for tumor location, clinical T stage, and radiation method, the mean radiation dose to the gastric fundus remained significantly and independently associated with an increased risk of anastomotic leakage (adjusted odds ratio 1.05 per 1-Gy increase, 95% confidence interval: 1.002 to 1.10, p = 0.043).

CONCLUSIONS

Efforts should be made to minimize the radiation dose to the gastric fundus when planning nCRT for esophageal cancer, because higher dose levels to the gastric fundus are associated with an increased risk of anastomotic leakage after subsequent transthoracic esophagectomy and cervical anastomosis.

Prognostic impact of extracapsular lymph node involvement after neoadjuvant therapy and oesophagectomy

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.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

Aortic Calcification Increases the Risk of Anastomotic Leakage After Ivor-Lewis Esophagectomy

BACKGROUND

Anastomotic leakage is associated with increased morbidity and mortality after esophagectomy. Calcification of the arteries supplying the gastric tube has been identified as a risk factor for leakage of the cervical anastomosis, but its potential contribution to the risk of intrathoracic anastomotic leakage has not been elucidated. This study evaluated the relationship between calcification and the occurrence of leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy.

METHODS

Consecutive patients who underwent minimally invasive esophagectomy for cancer at 2 institutions were analyzed. Diagnostic computed tomography images were used to detect calcification of the arteries supplying the gastric tube (eg, aorta, celiac axis). Multivariable logistic regression analysis was used to determine the relationship between vascular calcification and anastomotic leakage.

RESULTS

Of 167 included patients, anastomotic leakage occurred in 40 (24%). In univariable analysis, leakage was most frequently observed in patients with calcification of the aorta (major calcification: 37% leakage [16 of 43]; minor calcification: 32% [18 of 56]; no calcification: 9% [6 of 70], p < 0.001). Calcification of other studied arteries was not significantly associated with leakage. A significant association with leakage remained for minor (odds ratio, 5.4; 95% confidence interval, 1.7 to 16.5) and major (odds ratio, 7.0; 95% confidence interval, 1.9 to 26.4) aortic calcifications in multivariable analysis.

CONCLUSIONS

Atherosclerotic calcification of the aorta is an independent risk factor for leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy for cancer. The calcification scoring system may aid in patient selection and lead to earlier diagnosis of this potentially fatal complication.

Pretreatment Neutrophil to Lymphocyte Ratio Independently Predicts Disease-specific Survival in Resectable Gastroesophageal Junction and Gastric Adenocarcinoma

OBJECTIVE

Preoperative methods to estimate disease-specific survival (DSS) for resectable gastroesophageal (GE) junction and gastric adenocarcinoma are limited. We evaluated the relationship between DSS and pretreatment neutrophil to lymphocyte ratio (NLR).

BACKGROUND

The patient's inflammatory state is thought to be associated with oncologic outcomes, and NLR has been used as a simple and convenient marker for the systemic inflammatory response. Previous studies have suggested that NLR is associated with cancer-specific outcomes.

METHODS

A retrospective review of a prospectively maintained institutional database was undertaken to identify patients who underwent potentially curative resection for GE junction and gastric adenocarcinoma from 1998 to 2013. Clinicopathologic findings, pretreatment leukocyte values, and follow-up status were recorded. The Kaplan-Meier method was used to estimate DSS, and Cox proportional hazards models were used to evaluate the association between variables and DSS.

RESULTS

We identified 1498 patients who fulfilled our eligibility criteria. Univariate analysis showed that male sex, Caucasian race, increased T and N stage, GE junction location, moderate/poor differentiation, nonintestinal Lauren histology, and vascular and perineural invasion were associated with worse DSS. Elevated NLR was also associated with worse DSS [hazard ratio (HR) = 1.11; 95% CI: 1.08-1.14; P < 0.01]. On multivariate analysis, pretreatment NLR as a continuous variable was a highly significant independent predictor of DSS. For every unit increase in NLR, the risk of cancer-associated death increases by approximately 10% (HR = 1.10; 95% CI: 1.05-1.13; P < 0.0001).

CONCLUSIONS

In patients with resectable GE junction and gastric adenocarcinoma, pretreatment NLR independently predicts DSS. This and other clinical variables can be used in conjunction with cross-sectional imaging and endoscopic ultrasound as part of the preoperative risk stratification process.

Risk Assessment of Pancreatic Surgery by Surgical Apgar Score and Body Mass Index

Postoperative morbidity is high after pancreatic surgery. Recently, a simple and easy-to-use surgical complication prediction system, the surgical Apgar score (SAS), calculated using 3 intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate) has been proposed for general surgery. In this study, we evaluated the predictability of the SAS for severe complications after pancreatic surgery for pancreatic cancer. We investigated 189 patients who underwent pancreatic surgery at Kanagawa Cancer Center between 2005 and 2014. Clinicopathologic data, including the intraoperative parameters, were collected retrospectively. In this study, the patients with postoperative morbidities classified as Clavien-Dindo grade 2 or higher were classified as having severe complications. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for morbidity. Postoperative complications were identified in 73 patients, and the overall morbidity rate was 38.6%. The results of both univariate and multivariate analyses of various factors for overall operative morbidity showed that an SAS of 0 to 4 points and a body mass index ≥25 kg/m2 were significant independent risk factors for overall morbidity (P = 0.046 and P = 0.013). The SAS and body mass index were significant risk factors for surgical complications after pancreatic surgery for pancreatic cancer.

Drain amylase aids detection of anastomotic leak after esophagectomy

BACKGROUND

Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak.

METHODS

The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated.

RESULTS

Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak.

CONCLUSIONS

Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.

E-PASS score as a useful predictor of postoperative complications and mortality after colorectal surgery in elderly patients

PURPOSE

The aim of this study was to clarify whether a surgical-specific risk scoring system estimating the physiologic ability and surgical stress (E-PASS) score was useful for prediction of postoperative morbidity and mortality.

METHODS

The E-PASS score consists of the preoperative risk score (PRS), surgical stress score (SSS), and the comprehensive risk score (CRS). Conventional scoring systems [colorectal physiologic and operative severity score for the enumeration of mortality (CR-POSSUM) and the prognostic nutritional index (PNI)] were also examined. We retrospectively compared these scores in patients with or without postoperative complications. We assessed the relationship between these scores, clinicopathological features and postoperative mortality.

RESULTS

Postoperative complications developed in 78 patients (33%). American Society of Anesthesiologists score, performance status, PNI score, PRS, SSS, and CRS were significantly higher in patients with postoperative complications than in those without postoperative complications (p < 0.05). The area under the receiver operating characteristic curve (AUC) was highest for E-PASS [E-PASS (PRS, 0.74; SSS, 0.62; CRS, 0.78), PNI (0.62), CR-POSSUM (PS, 0.57; OSS, 0.52)]. Multivariate logistic analysis identified CRS ≥ 0.2 as a significant determinant of postoperative complications (p < 0.01; hazard ratio, 4.84). Overall survival was significantly better in the CRS < 0.2 group than in the CRS > 0.2 group (p < 0.01).

CONCLUSIONS

The E-PASS score system was a useful predictor of postoperative complications and mortality, especially in patients with advanced age.

Postoperative Infectious Complications are Associated with Adverse Oncologic Outcomes in Esophageal Cancer Patients Undergoing Preoperative Chemotherapy

BACKGROUND

For some types of cancer, postoperative complications can negatively influence survival, but the association between these complications and oncological outcomes is unclear for patients with esophageal cancer who receive preoperative treatments.

METHODS

Data were retrospectively analyzed for patients who underwent curative resection following preoperative chemotherapy for esophageal squamous cell carcinoma from 2001 to 2011. Clinicopathological parameters and cancer-specific survival (CSS) were compared between patients with and without severe postoperative complications, grade III or higher, using the Clavien-Dindo classification.

RESULTS

Of 255 patients identified, 104 (40.8 %) postoperatively developed severe complications. The most common complication was atelectasis in 61 (23.9 %), followed by pulmonary infection in 22 (8.6 %). Three-field lymphadenectomy, longer operation time, and more blood loss were significantly associated with a higher incidence of severe complications. Multivariate analysis of CSS revealed severe complications [hazard ratio (HR) = 1.642, 95 % confidence interval (95 % CI) 1.095-2.460, p = 0.016] as a significant prognostic factor along with pT stage [HR = 2.081, 95 % CI 1.351-3.266, p < 0.001] and pN stage [HR = 3.724, 95 % CI 2.111-7.126, p < 0.001], whereas postoperative serum C-reactive protein value was not statistically significant. Among all complications, severe pulmonary infection was the only independent prognostic factor [HR = 2.504, 95 % CI 1.308-4.427, p = 0.007].

CONCLUSIONS

The incidence of postoperative infectious complications, in particular pulmonary infection, is associated with unfavorable prognosis in patients with esophageal cancer undergoing preoperative chemotherapy.

Quality Management and Key Performance Indicators in Oncologic Esophageal Surgery

Ranking systems and comparisons of quality and performance indicators will be of increasing relevance for complex "high-risk" procedures such as esophageal cancer surgery. The identification of evidence-based standards relevant for key performance indicators in esophageal surgery is essential for establishing monitoring systems and furthermore a requirement to enhance treatment quality. In the course of this review, we analyze the key performance indicators case volume, radicality of resection, and postoperative morbidity and mortality, leading to continuous quality improvement. Ranking systems established on this basis will gain increased relevance in highly complex procedures within the national and international comparison and furthermore improve the treatment of patients with esophageal carcinoma.

18F-FDG PET-CT after Neoadjuvant Chemoradiotherapy in Esophageal Cancer Patients to Optimize Surgical Decision Making

BACKGROUND

Prognosis of esophageal cancer patients can be significantly improved by neoadjuvant chemoradiotherapy (nCRT). Given the aggressive nature of esophageal tumors, it is conceivable that in a significant portion of patients treated with nCRT, dissemination already becomes manifest during the period of nCRT. The aim of this retrospective study was to determine the value and diagnostic accuracy of PET-CT after neoadjuvant chemoradiotherapy to identify patients with metastases preoperatively in order to prevent non-curative surgery.

METHODS

From January 2011 until February 2013 esophageal cancer patients deemed eligible for a curative approach with nCRT and surgical resection underwent a PET-CT after completion of nCRT. If abnormalities on PET-CT were suspected metastases, histological proof was acquired. A clinical decision model was designed to assess the cost-effectiveness of this diagnostic strategy.

RESULTS

156 patients underwent a PET-CT after nCRT. In 31 patients (19.9%) PET-CT showed abnormalities suspicious for dissemination, resulting in 17 cases of proven metastases (10.9%). Of the patients without proven metastases 133 patients were operated. In 6 of these 133 cases distant metastases were detected intraoperatively, corresponding to 4.5% false-negative results. The standard introduction of a post-neoadjuvant therapy PET-CT led to a reduction of overall health care costs per patient compared to a scenario without restaging with PET-CT ($34,088 vs. $36,490).

CONCLUSION

In 10.9% of esophageal cancer patients distant metastases were detected by standard PET-CT after neoadjuvant chemoradiotherapy. To avoid non-curative resections we advocate post-neoadjuvant therapy PET-CT as a cost-effective step in the standard work-up of candidates for surgery.

Prolonged postoperative length of stay is associated with poor overall survival after an esophagectomy for esophageal cancer

BACKGROUND

To investigate the impact of prolonged length of stay (LoS) on long-term mortality in patients who have undergone curative resection for esophageal cancer (EC).

METHODS

Between January 2001 and December 2009, patients who underwent an esophagectomy for EC at Fudan University Shanghai Cancer Center were enrolled in this study. We retrospectively analyzed the medical charts of all of the enrolled patients. To determine the effect of postoperative LoS on long-term survival, we separated the patients into three groups based on the lengths of their postoperative LoS, including an LoS of less than 2 weeks (Group 1, ≤2 W), an LoS between 2 and 3 weeks (Group 2, ≤3 W) and an LoS of more than 3 weeks (Group 3, >3 W). Perioperative and long-term outcomes were compared between the groups.

RESULTS

In total, 348 patients were included in this study. All of the patients underwent an esophagectomy with 3-field lymph node dissection (3FLND). The median postoperative hospital stay was 14 days (range: 8-153 days). Complications were observed in 123 patients (15.9% in Group 1 vs. 73.2% in Group 2 vs. 96.6% in Group 3, P<0.001). The median duration of follow-up was 39 months (range: 3-120 months). There were significant reductions in preventive adjuvant therapy (P=0.003) and postoperative salvage therapy (P<0.001) among the three groups. The 5-year survival rate was significantly different among the groups (43% vs. 36% vs. 29%, respectively, P=0.006). There was no difference in the 5-year disease-free survival rate among the three groups (23% vs. 21% vs. 19%, P=0.238).

CONCLUSIONS

Prolonged LoS was significantly associated with reduced rates of overall survival (OS). The insufficient administration of adjuvant therapy may partly account for these findings.

International Consensus on Standardization of Data Collection for Complications Associated With Esophagectomy: Esophagectomy Complications Consensus Group (ECCG)

INTRODUCTION

Perioperative complications influence long- and short-term outcomes after esophagectomy. The absence of a standardized system for defining and recording complications and quality measures after esophageal resection has meant that there is wide variation in evaluating their impact on these outcomes.

METHODS

The Esophageal Complications Consensus Group comprised 21 high-volume esophageal surgeons from 14 countries, supported by all the major thoracic and upper gastrointestinal professional societies. Delphi surveys and group meetings were used to achieve a consensus on standardized methods for defining complications and quality measures that could be collected in institutional databases and national audits.

RESULTS

A standardized list of complications was created to provide a template for recording individual complications associated with esophagectomy. Where possible, these were linked to preexisting international definitions. A Delphi survey facilitated production of specific definitions for anastomotic leak, conduit necrosis, chyle leak, and recurrent nerve palsy. An additional Delphi survey documented consensus regarding critical quality parameters recommended for routine inclusion in databases. These quality parameters were documentation on mortality, comorbidities, completeness of data collection, blood transfusion, grading of complication severity, changes in level of care, discharge location, and readmission rates.

CONCLUSIONS

The proposed system for defining and recording perioperative complications associated with esophagectomy provides an infrastructure to standardize international data collection and facilitate future comparative studies and quality improvement projects.

Postoperative complications do not impact on recurrence and survival after curative resection of gastric cancer

BACKGROUND

We assessed the impact of complications on recurrence and survival after curative gastric cancer resection.

METHODS

Patients undergoing R0 resections between 1990 and 2009 were identified in a prospectively maintained database and were categorized by presence of any complication Clavien-Dindo (CD) ≥ II, sepsis or intra-abdominal sepsis. Cox regression analyses to relate complications and clinico-pathological variables to time to recurrence (TTR) and overall survival (OS) were performed.

RESULTS

A total of 271 patients were included with a median follow-up of 149.9 months (range 140.1-159.9). Complications CD ≥ II occurred in 162 (59.8%) patients, sepsis in 66 (22.5%), and intra-abdominal sepsis in 37 (13.6%). Recurrence developed in 88 (32.4%) patients. Independent predictors of short TTR were pTNM stage (IIIB-IIIC vs. IA-IIA) (hazard ratio [HR] = 37.55, 95% confidence interval [CI] 17.57-80.24; p < 0.001), D1 lymphadenectomy (HR = 3.14, 95% CI 1.94-5.07; p < 0.001), and male gender (HR = 1.65, 95% CI 1.06-2.57; p = 0.026). pTNM stage (IIIB-IIIC vs. IA-IIA, HR = 10.28, 95% CI 6.51-16.23; p < 0.001), male gender (HR = 1.64, 95% CI 1.17-2.31; p = 0.005), age (HR = 1.03, 95% CI 1.02-1.05; p < 0.001), and adjuvant therapy (HR = 0.55, 95% CI 0.37-0.83; p = 0.004) were identified as independent predictors of OS..

CONCLUSIONS

Evidence provided by this study does not support a negative impact of postoperative complications CD ≥ II, sepsis, and intra-abdominal sepsis on the oncologic outcome after curative gastric cancer resection.

Predictive Factors of Recurrence in Patients with Pathological Complete Response After Esophagectomy Following Neoadjuvant Chemoradiotherapy for Esophageal Cancer: A Multicenter Study

BACKGROUND

Minimal data have previously emerged from studies regarding the factors associated with recurrence in patients with ypT0N0M0 status. The purpose of the study was to predict survival and recurrence in patients with pathological complete response (pCR) following chemoradiotherapy (CRT) and surgery for esophageal cancer (EC).

METHODS

Among 2944 consecutive patients with EC operations in 30 centers between 2000 and 2010, patients treated with neoadjuvant CRT followed by surgery who achieved pCR (n = 191) were analyzed. The factors associated with survival and recurrence were analyzed using a Cox proportional hazard regression analysis.

RESULTS

Among 593 patients who underwent neoadjuvant CRT followed by esophagectomy, pCR was observed in 191 patients (32.2 %). Recurrence occurred in 56 (29.3 %) patients. The median time to recurrence was 12 months. The factors associated with recurrence were postoperative complications grade 3-4 [odds ratio (OR): 2.100; 95 % confidence interval (CI) 1.008-4.366; p = 0.048) and adenocarcinoma histologic subtype (OR 2.008; 95 % CI 0.1.06-0.3.80; p = 0.032). The median overall survival was 63 months (95 % CI 39.3-87.1), and the median disease-free survival was 48 months (95 % CI 18.3-77.4). Age (>65 years) [hazard ratio (HR): 2.166; 95 % CI 1.170-4.010; p = 0.014), postoperative complications grades 3-4 [HR 2.099; 95 % CI 1.137-3.878; p = 0.018], and radiation dose (<40 Gy) (HR 0.361; 95 % CI 0.159-0.820; p = 0.015) were identified as factors associated with survival.

CONCLUSIONS

An intensive follow-up may be beneficial for patients with EC who achieve pCR and who develop major postoperative complications or the adenocarcinoma histologic subtype.

Conduit Vascular Evaluation is Associated with Reduction in Anastomotic Leak After Esophagectomy

BACKGROUND

Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. A major factor determining anastomotic success is an adequate blood supply to the conduit. The aim of this study was to determine the impact of intraoperative evaluation of the conduit's vascular supply on anastomotic failure after esophagectomy.

METHODS

We retrospectively analyzed data from 90 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. A change in surgical practice occurred after 60 cases were completed, when we introduced the use of intraoperative indocyanine green fluorescence angiography and Doppler examination to evaluate blood supply and assist in construction of the conduit. The leak rates before and after implementation of conduit vascular evaluation were compared.

RESULTS

After the introduction of intraoperative vascular evaluation of the gastric conduit, we noted a dramatic decrease in the rate of anastomotic leak from 20 % in the first 60 patients to 0 % in the succeeding 30 patients.

CONCLUSIONS

Intraoperative vascular evaluation with indocyanine green fluorescence imaging and Doppler examination of the gastric conduit used to assist reconstruction after esophagectomy allows for enhanced construction of the conduit that maximizes blood supply to the anastomosis. This change in practice was associated with a significant reduction in anastomotic leak rate.

Impact of infectious complications on gastric cancer recurrence

BACKGROUND

Postoperative infectious complications increase disease recurrence in colorectal cancer patients. We herein investigated the impact of infectious complications on gastric cancer recurrence after curative surgery.

METHODS

In total, 502 patients who underwent R0 resection for gastric cancer were reviewed. Patients were classified into those with infectious complications (IC group) and those without infectious complications (NO group). The risk factors for recurrence-free survival (RFS) were identified.

RESULTS

Infectious complications, which occurred in 52 patients (10.4%), included pneumonia, ileus with a systemic inflammatory reaction, anastomotic leakage, and intraperitoneal abscess. The overall 5-year RFS rate was 83% in the NO group and 58% in the IC group (p = 0.000). Multivariate analysis demonstrated that age, ASA score, stage, and infectious complications were significant predictors of RFS.

CONCLUSIONS

Infectious complications were a risk factor for gastric cancer recurrence. To avoid causing infectious complications, the surgical procedure, surgical strategy, and perioperative care should be carefully planned.

The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma

BACKGROUND

The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy (PD) for adenocarcinoma is still unclear.

METHODS

A retrospective review of all patients undergoing PD at our institution between 1995 and 2011 was performed. Clinicopathological data, including Clavien-Dindo complication grade, time to adjuvant therapy (TTA), and survival, were analyzed.

RESULTS

A total of 1,144 patients underwent PD for adenocarcinoma between 1995 and 2011. The overall complication rate was 49.1 % and clinically severe complications (≥IIIb) occurred in 4.2 %. Overall, 621 patients (54.3 %) were known to have received adjuvant therapy. The median TTA was 60 days. Although the presence of a complication was associated with a delay in TTA (p = 0.002), the grade of complication was not (p = 0.112). On multivariate analysis, only age > 68 years (p < 0.001) and length of stay >9 days (p = 0.002) correlated with no adjuvant therapy. Patients with postoperative complications were more likely to receive single adjuvant chemotherapy or radiation therapy (31.4 %) than were patients without complications (17.1 %; p < 0.001). Patients without a complication had a longer median survival compared with patients who experienced complications (19.5 vs. 16.1 months; p = 0.001). Patients without complications who received adjuvant therapy had longer median survival than patients with complications who received no adjuvant therapy (22.5 vs. 10.7 months; p < 0.001). Multivariate analysis demonstrated that complications [hazard ratio (HR) 1.16; p = 0.023] and adjuvant therapy (HR 0.67; p < 0.001) were related to survival.

CONCLUSION

Complications and no adjuvant therapy are common following PD for adenocarcinoma. Postoperative complications delay TTA and reduce the likelihood of multimodality adjuvant therapy. Identifying patients at increased risk for complications and those unlikely to receive adjuvant therapy warrants further investigation as they may benefit from a neoadjuvant approach.

Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: a two-center study of 101 patients

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective but potentially morbid treatment for colorectal cancer peritoneal metastases. The impact of treatment-related morbidity on long-term survival has been reported in various malignancies, but it has never been assessed in this clinical setting.

OBJECTIVE

The aim of this study was to assess the impact of major postoperative complications on oncological outcomes after cytoreduction and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases.

DESIGN

Two prospective databases were reviewed. Major complications were defined as grade 3 to 5 according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The extent of peritoneal involvement was scored by the use of the Peritoneal Cancer Index.

SETTINGS

This study was conducted in 2 high-volume peritoneal malignancy management centers.

PATIENTS

One hundred one consecutive patients with peritoneal metastases potentially amenable to macroscopically complete cytoreduction were selected.

INTERVENTIONS

Peritonectomy procedures and multivisceral resections were used to remove all macroscopic tumor, and mitomycin-C plus cisplatin-based hyperthermic intraperitoneal chemotherapy was used to control microscopic residual disease.

MAIN OUTCOME MEASURES

The primary outcomes measured were overall and disease-specific survival.

RESULTS

Mortality and major morbidity were 3.0%, and 23.8%. Median follow-up was 44.9 months (95% CI, 24.1-65.7). Five-year disease-specific survival was 14.3% for patients who experienced major complications and 52.3% for those who did not (p = 0.001). Five-year overall survival was 11.7% for patients who experienced major complications, and 58.8% for those who did not (p = 0.003). At multivariate analysis, major morbidity correlated to both worse overall and disease-specific survival, along with a Peritoneal Cancer Index >19, and suboptimal cytoreduction. Poor performance status correlated only to worse disease-specific survival, and liver metastases correlated to worse overall survival. Longer operative time (OR, 4.1; 95% CI, 1.3-12.6; p = 0.01) and Peritoneal Cancer Index >19 (OR, 2.6; 95% CI, 1.1-6.0; p = 0.02) were independent risk factors for major morbidity.

LIMITATIONS

This study is limited by its observational design.

CONCLUSIONS

The prevention of major complications, by refining surgical technique and patient selection, is crucial because it affects oncologic outcome.

A new clinical scoring system to define pneumonia following esophagectomy for cancer

BACKGROUND

Pneumonia is a frequently observed complication following esophagectomy. The lack of a uniform definition of pneumonia leads to large variations of pneumonia rates in literature. This study was designed to develop a scoring system for diagnosing pneumonia following esophagectomy at the hospital ward.

METHODS

In a prospective cohort study of esophagectomy patients, known risk factors for pneumonia, temperature, leukocyte count, pulmonary radiography and sputum culture added were evaluated. Primary outcome was defined as the decision to treat suspected pneumonia. Multivariate Cox regression analysis with backward selection was used to identify predictors of pneumonia treatment.

RESULTS

The majority of postoperative pneumonia treatments (88.2%) occurred at the hospital ward, where treatment was observed in 67 (36.2%) of 185 patients. Independent diagnostic determinants for pneumonia treatment were temperature (hazard ratio (HR) = 1.283, p = 0.073), leukocyte count (HR = 1.040, p = 0.078) and pulmonary radiography (HR >11.0, p = 0.000). Sputum culture did not influence the decision to treat pneumonia. These findings were used to develop a scoring system which includes temperature, leukocyte count and pulmonary radiography.

CONCLUSION

The decision to treat pneumonia is based on temperature, leukocyte count and pulmonary radiography findings. The proposed clinical scoring system for pneumonia following esophagectomy at the hospital ward has the potential to aid clinical practice and improve comparability of future research in esophageal cancer surgery.

Reoperation after oesophageal cancer surgery in relation to long-term survival: a population-based cohort study

OBJECTIVES

The influence of reoperation on long-term prognosis is unknown. In this large population-based cohort study, it was aimed to investigate the influence of a reoperation within 30 days of oesophageal cancer resection on survival even after excluding the initial postoperative period.

DESIGN

This was a nationwide population-based retrospective cohort study.

SETTING

All hospitals performing oesophageal cancer resections during the study period (1987-2010) in Sweden.

PARTICIPANTS

Patients operated for oesophageal cancer with curative intent in 1987-2010.

PRIMARY AND SECONDARY OUTCOMES

Adjusted HRs of all cause, early and late mortality up to 5 years after reoperation following oesophageal cancer resection.

RESULTS

Among 1822 included patients, the 200 (11%) who were reoperated had a 27% increased HR of all-cause mortality (adjusted HR 1.27, 95% CI 1.05 to 1.53) and 28% increased HR of disease-specific mortality (adjusted HR 1.28, 95% CI 1.04 to 1.59), compared to those not reoperated. Reoperation for anastomotic insufficiency in particular was followed by an increased mortality (adjusted HR 1.82, 95% CI 1.19 to 2.76).

CONCLUSIONS

This large and population-based nationwide cohort study shows that reoperation within 30 days after primary oesophageal resection was associated with increased mortality, even after excluding the initial 3 months after surgery. This finding stresses the need to consider any actions that might prevent complications and reoperation after oesophageal cancer resection.

Radiologic versus endoscopic evaluation of the conduit after esophageal resection: a prospective, blinded, intraindividually controlled diagnostic study

BACKGROUND

Anastomotic leakage is a major complication in esophageal surgery. Although contrast swallow is performed by many surgical centers before reintroduction of oral intake to exclude anastomotic leakage postoperatively, endoscopy is increasingly used in this situation and may be superior. This study compares radiographic contrast study and endoscopy for the identification of local complications after subtotal esophagectomy.

METHODS

Between January 2006 and September 2007, a prospective, blinded, intraindividually controlled study was conducted in patients who underwent transthoracic esophagectomy due to esophageal cancer. A radiographic contrast study was performed prior to endoscopy on postoperative day 5-7. Technical feasibility, sensitivity, and specificity of the radiologic and endoscopic evaluations of the esophageal substitute were described.

RESULTS

Radiographic contrast study was possible in only 64% of the patients (35 of 55). The contrast study could not be performed in 20 patients due to contraindications or mechanical ventilation. Endoscopy could be performed in all patients (p < 0.001). Pathologic findings were detected in 13 patients by endoscopy but in only 1 patient by contrast swallow. Leakage of the anastomosis or the conduit was correctly detected in 7 patients by endoscopy but in only 1 patient by contrast swallow (p = 0.01). Endoscopy detected focal conduit necrosis or ischemia in six additional patients. Contrast studies showed false-positive results in two patients. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of the contrast study were only 20 and 94%. No complications resulted from postoperative endoscopy or radiologic imaging.

CONCLUSIONS

Endoscopic evaluation of the esophageal substitute in the early postoperative course is possible in all patients without complications. Endoscopy is superior to the contrast study in detecting pathological findings after esophageal reconstruction. Radiologic contrast swallow in the early postoperative days is often not possible, has no further relevance, and should be replaced by endoscopic evaluation.