Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

Pulmonary complications in patients with chronic obstructive pulmonary disease following transthoracic esophagectomy

AIM: To investigate the incidence of various types of postoperative pulmonary complications (POPCs) and to evaluate the significance of perioperative arterial blood gases in patients with esophageal cancer accompanied with chronic obstructive pulmonary disease (COPD) after esophagectomy.

MEHTODS: Three hundred and fifty-eight patients were divided into POPC group and COPD group. We performed a retrospective review of the 358 consecutive patients after esophagectomy for esophageal cancer with or without COPD to assess the possible influence of COPD on postoperative pulmonary complications. We classified COPD into four grades according to percent-predicted forced expiratory volume in 1 s (FEV1) and analyzed the incidence rate of complications among the four grades. Perioperative arterial blood gases were tested in patients with or without pulmonary complications in COPD group and compared with POPC group.

RESULTS: Patients with COPD (29/86, 33.7%) had more pulmonary complications than those without COPD (36/272, 13.2%) (P < 0.001). Pneumonia (15/29, 51.7%), atelectasis (13/29, 44.8%), prolonged O₂ supplement (10/29, 34.5%), and prolonged mechanical ventilation (8/29, 27.6%) were the major complications in COPD group. Moreover, patients with severe COPD (gradeIIB, FEV1 < 50% of predicted) had more POPCs than those with moderate(gradeIIA, 50%-80% of predicted) and mild (gradeI≥ 80% of predicted) COPD (P < 0.05). PaO₂ was decreased and PaCO₂ was increased in patients with pulmonary complications in COPD group in the first postoperative week.

CONCLUSION: The criteria of COPD are the critical predictor for pulmonary complications in esophageal cancer patients undergoing esophagectomy. Severity of COPD affects the incidence rate of the pulmonary complication, and percent-predicted FEV1 is a good predictive variable for pulmonary complication in patients with COPD. Arterial blood gases are helpful in directing perioperative management.

Prediction of survival from carcinoma of oesophagus and oesophago-gastric junction following surgical resection using an artificial neural network

AIM

The aim of this study was to assess the ability of artificial neural network (ANN) in predicting survival in patients undergoing surgical resection for carcinoma of oesophagus and oesophago-gastric junction.

METHODS

From January 1995 to August 2004 patients who underwent surgery for oesophageal and gastric carcinoma were identified. Biographical data, body mass index and pathological minimal cancer dataset were used to design an ANN. Post-operative survival was assessed at 1 and 3 years. Sixty percent of data was used to train and validate the ANN and 40% was used to evaluate the accuracy of trained ANN in predicting survival. This was compared with Union Internacional Contra la Cancrum UICC TNM classification system.

RESULTS

Two hundred and sixteen patients underwent resectional surgery for oesophageal and OGJ carcinoma. The accuracy of the ANN in predicting survival at 1 and 3 years was 88% (sensitivity: 92.3%, specificity: 84.5%, DP = 2.3) and 91.5% (sensitivity of 94.61%, specificity: 88%, DP = 2.72), respectively. These figures were significantly better than 1- and 3-year survival predictions using the UICC TNM classification system 71.6% (sensitivity of 66.4%, specificity: 75.5%, and DP < 1) and 74.7% (sensitivity of 70.5%, specificity: 74.9%, DP < 1), respectively (P < 0.01) (P < 0.05).

CONCLUSION

ANNs are superior to the UICC TNM classification system in correlating with survival following resection of carcinoma of oesophagus and OG junction and can become valuable tools in the management of patients with oesophageal carcinoma.

[Minimally invasive esophagectomy: prospective evaluation of laparoscopic gastric mobilization]

OBJECTIVE

Esophagectomy carries high morbidity, mainly due to respiratory complications. In digestive surgery, postoperative outcome is generally improved by minimally invasive surgery. A prospective study was conducted to evaluate feasibility and postoperative outcome of minimally invasive esophagectomy (MIE).

METHODS

From July 2001 to June 2004, 20 patients underwent esophagectomy with laparoscopic gastric mobilization (LGM) for squamous cell carcinoma (N=11), adenocarcinoma (N=7), Barrett's esophagus with high-grade dysplasia (N=1), and long peptic stricture (N=1). Tumours (N=19) were located on the cardia (N=5), on the lower third of the oesophagus (N=10), on the median third (N=3), and on the upper third (N=1). Following LGM, transthoracic (N=19) or transhiatal (N=1) oesophagectomy was performed.

RESULTS

Complete LGM was achieved in all cases. Mean operative time for LGM was 197+/-48 minutes. In the 19 patients operated for tumours, 18 underwent R0 resection. Eleven patients (55%) developed postoperative complications, mainly (30%) respiratory. Intrathoracic anastomotic leakage occurred in 2 patients, with favourable outcome. Pylorospasm (N=1) was the only intraabdominal complication. One patient died (5%).

CONCLUSION

Esophagectomy with LGM is feasible with few specific complications. However, no decrease in morbidity could be observed with this technique. Further studies are required to evaluate if thoracoscopy could improve the postoperative course after LGM and to validate oncologic safety of MIE.

The Effects of Perioperative Blood Transfusion on Morbidity and Mortality After Esophagectomy

The effect of blood transfusion on outcomes in esophageal surgery remains controversial. The contrasting conclusions drawn from a number of retrospective analyses with different methodologies create a landscape that is difficult to interpret. Because of the scope of esophageal resection, the need for blood transfusion cannot be eliminated. What recommendations then, if any, can be made for the practicing surgeon? First, surgeons and anesthesiologists need to reevaluate their transfusion thresholds. The age-old practice of keeping the hemoglobin above 10 g/dL has very little evidence-based support. A multicenter, randomized, controlled clinical trial in Canada demonstrated that a restrictive strategy of blood transfusion, in which patients were transfused only for a hemoglobin level of less than 7 g/dL, was at least as effective as and possibly was superior to a liberal transfusion strategy in critically ill patients. It has also been estimated that more than 25% of patients undergoing colorectal resections may receive at least one unit of unnecessary blood. Further, the immediate reduction in the hemoglobin concentration caused by the normovolemic hemodilution associated with surgery and crystalloid fluid replacement is not associated with any increased morbidity or mortality. If these data are examined in the context of the results of Langley and Tachibana indicating that a threshold amount of blood needs to be transfused to impact outcomes, it becomes even more important to limit transfusion to only the amount that is essential. Thus, surgeons and anesthesiologists should adopt a more stringent set of requirements for blood transfusion. Second, with the proven feasibility and reduction in infectious complications associated with autologous blood-donation programs, any patient who meets the criteria discussed here should be encouraged to participate in such a program. Although the effect of autologous blood on cancer outcomes remains unclear, the other advantages certainly make such a program worthy of consideration. This discussion leads to a final point, namely that patients should be encouraged, whenever possible, to participate in clinical trial research. The only way that the community of surgeons treating patients who have esophageal cancer can hope to address properly the question of how blood transfusion affects outcomes is with well-designed clinical trials. A large, multicenter, randomized trial (level I) would be ideal. Short of such a trial, inclusion criteria and study methodology should be discussed among various institutions to avoid the differences in studies that make direct comparisons of results among different investigators difficult and potentially meaningless. This measure would at least allow different level II to IV data to be compared directly with some validity.

The prevention and management of perioperative complications

The most important issues in perioperative complications of oesophagectomy are prevention, early detection and appropriate management. Anastomotic leakage is the most frequent technical surgical complication. Prevention comprises avoidance of tension or impaired vascularization of the conduit and meticulous suture technique. Management includes early diagnosis, conservative treatment or endoscopic stenting of contained leakage, and re-operation of non-contained insufficiency. All other surgical complications - such as bleeding, tracheobronchial lesions or chylothorax - are rare and warrant special therapeutic modalities. The main general non-surgical complication is postoperative pneumonia, which should be prevented by effective pain control (especially peridural catheter) and appropriate techniques of artificial respiration. Special attention should be offered to postoperative tachyarrhythmias and alcohol withdrawal syndrome. Prevention of complications also includes exclusion of patients with high operative risk based on scores and specific preoperative treatment of risk factors.

[Complications following oesophagectomy: mechanism, detection, treatment and prevention]

Oesophageal surgery remains a relatively morbid operation with potentially devastating complications that can be minimized by prevention, early recognition, and appropriate management. Anastomotic leak, conduit necrosis, and pulmonary failure are the most serious complications. The management of complications following oesophagectomy is reviewed in the following section.

Locally Recurrent Esophageal Carcinoma: When is Re-Resection Indicated?

BACKGROUND

Limited locally recurrent esophageal carcinoma is rare, and little is known regarding effectiveness of re-resection.

METHODS

Medical records of 27 consecutive patients with locally recurrent esophageal carcinoma who underwent reoperation at our institution between February 1974 and January 2003 were analyzed.

RESULTS

The original and recurrent cancer cell types were identical in all patients. Median disease-free interval was 19.4 months (range, 2.5 to 170 months). Recurrence was at the anastomosis in 23 patients (85%), esophageal remnant in 3 (11%), and stomach in 1 (4%). Ten patients had completion gastrectomy and partial esophagectomy, and 9 had resection of the anastomosis. The remaining 8 patients were found intraoperatively to have unresectable disease and underwent biopsy only. Re-resection was complete in 15 of the 19 patients resected (79%). Four patients had microscopic cancer at the resection margins. Reconstruction was with colon in 10 patients and esophagogastrostomy in 9. There were 2 deaths (operative mortality, 7%). Complications occurred in 16 patients (59%). Arrhythmia and anastomotic leak were the most common complications and each occurred in 7 patients (26%). Factors favorably associated with survival were disease-free interval greater than 2 years (p < or = 0.05) and complete re-resection (p < or = 0.02). Two-, three-, and five-year survival for patients completely re-resected was 62%, 44%, and 35%, respectively. Survival for patients who had incomplete re-resections was 18% at 2 years and zero at 3 years.

CONCLUSIONS

Re-resection of locally recurrent esophageal carcinoma is associated with considerable morbidity. However, long-term survival is possible in patients with a long disease-free interval or a complete re-resection.

[Cervical and upper-third thoracic oesophageal carcinoma: a single pathological entity?]

AIM OF THE STUDY

Cervical and upper-third thoracic oesophageal carcinomas are considered as a single pathological entity. The aim of this study was to compare postoperative and oncological results after surgical resection in these two locations.

MATERIAL AND METHODS

Postoperative and oncological results were compared retrospectively in 155 patients who underwent surgery for carcinoma of the cervical (C group, n = 21) or upper-third thoracic (TS group, n = 134) oesophagus.

RESULTS

The two groups were comparable regarding the pre-, peroperative and histological data. Postoperative mortality and morbidity rates in the C and TS groups were 4.8% and 10.4% (P= 0.413) and 57.1 and 50.7% (P= 0.585), respectively. R0 resection and recurrence rates were 61.9% and 73.1% (P= 0.289) and 50.0% and 51.1% (P= 0.941), respectively. Five-year survival rates were 0% and 35% in the overall population (P= 0.098) and 0 and 49% in the R0 population (P= 0.047), respectively. By multivariate analysis, cervical location of the tumour was found to be an independent factor of poor prognosis (relative risk= 3.1, 95% confidence interval= 1.3-7.8, P= 0.014).

CONCLUSION

Prognosis after surgical resection of cervical oesophagus carcinoma is very poor. Surgery in this location should be proposed in case of chemoradiation failure.