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

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Analysis of the influencing factors in the long-term survival of esophageal cancer

Background

To analyze the prognosis and diagnostic value of relevant hematological indexes on the survival status of patients with esophageal squamous cell carcinoma after radical surgery.

Methods

This study included 206 patients with esophageal cancer who underwent surgical R0 resection. The data, including the basic information, preoperative blood routine, albumin, fibrinogen, surgery-related information, postoperative pathology, and overall survival, of the patients were compared.

Results

The survival and death groups showed a significant difference in overall survival (OS), the degree of differentiation, depth of infiltration, pathological stage, vascular infiltration, nerve infiltration, fibrinogen, white blood cell, neutrophils, platelet, and platelet hematocrit (P<0.05). Tumor located in the middle thorax, larger lesion length, deeper invasion, later pathological stage, vascular infiltration, nerve infiltration, lymph node metastasis, cardiovascular disease, and higher smoking grade were risk factors for poor prognosis of esophageal squamous cell carcinoma (ESCC) (P<0.05). Cardiovascular disease, lower differentiation, tumor located in the middle thorax, and nerve infiltration were independent risk factors for the reduction of survival time of patients with ESCC (P<0.05).

Conclusions

History of cardiovascular disease, tumor located in the middle chest, poorly differentiated esophageal squamous cell carcinoma, visible nerve cancer invasion, hematocrit (HCT), mean erythrocyte hemoglobin concentration (MCHC), and hemoglobin (HB) are independent risk factors for the long-term survival of patients with ESCC.

EARLY POSTOPERATIVE OUTCOMES OF THE ESOPHAGECTOMY MINIMALLY INVASIVE IN ESOPHAGEAL CANCER

BACKGROUND

The incidence of esophageal cancer is high in some regions and the surgical treatment requires reference centers, with high volume, to make surgery feasible.

AIMS

To evaluate patients undergoing minimally invasive esophagectomy by thoracoscopy in prone position for the treatment of esophageal cancer and to recognize the experience acquired over time in our service after the introduction of this technique.

METHODS

From January 2012 to August 2021, all patients who underwent the minimally invasive esophagectomy for esophageal cancer were retrospectively analyzed. In order to assess the factors associated with the predefined outcomes as fistula, pneumonia, and intrahospital death, we performed univariate and multivariate logistic regression analyses, accounting for age as an important factor.

RESULTS

Sixty-six patients were studied, with mean age of 59.5 years. The main histological type was squamous cell carcinoma (81.8%). The incidence of postoperative pneumonia and fistula was 38% and 33.3%, respectively. Eight patients died during this period. The patient's age, T and N stages, the year the procedure was performed, and postoperative pneumonia development were factors that influenced postoperative death. There was a 24% reduction in the chance of mortality each year, associated with the learning curve of our service.

CONCLUSIONS

The present study presented the importance of the team's experience and the concentration of the treatment of patients with esophageal cancer in reference centers, allowing to significantly improve the postoperative outcomes.

Risk factors for early local lymph node recurrence of thoracic ESCC after McKeown esophagectomy

Objectives

Even underwent radical resection, some patients of thoracic esophageal squamous cell carcinoma (ESCC) are still exposed to local recurrence in a short time. To this end, the present study sought to differentiate patient subgroups by assessing risk factors for postoperative early (within one year) local lymph node recurrence (PELLNR).

Methods

ESCC patients were selected from a prospective database, and divided into high- and low-risk groups according to the time of their local lymphatic recurrence (within one year or later). Survival analysis was conducted by the Cox regression model to evaluate the overall survival (OS) between the two groups. The hazard ratio (HR) and 95% confidence interval (CI) of different variables were also calculated. Logistic regression analysis was used to explore the high-risk factors for PELLNR with the odds ratio (OR) and 95% CI calculated.

Results

A total of 432 cases were included. The survival of patients in the high-risk group (n = 47) was significantly inferior to the low-risk group (n = 385) (HR = 11.331, 95% CI: 6.870-16.688, P < 0.001). The 1-year, 3-year, and 5-year OS rate of the patients in high/low-risk groups were 74.5% vs. 100%, 17% vs. 88.8%, and 11.3% vs. 79.2%, respectively (P < 0.001). Risk factors for local lymph node recurrence within one year included upper thoracic location (OR = 4.071, 95% CI: 1.499-11.055, P = 0.006), advanced T staging (pT3-4, OR = 3.258, 95% CI: 1.547-6.861, P = 0.002), advanced N staging (pN2-3, OR = 5.195, 95% CI: 2.269-11.894, P < 0.001), and neoadjuvant treatment (OR = 3.609, 95% CI: 1.716-7.589, P = 0.001). In neoadjuvant therapy subgroup, high-risk group still had unfavorable survival (Log-rank P < 0.001). Multivariate analysis demonstrated that upper thoracic location (OR = 5.064, 95% CI: 1.485-17.261, P = 0.010) and advanced N staging (pN2-3) (OR = 5.999, 95% CI: 1.986-18.115, P = 0.001) were independent risk factors for early local lymphatic recurrence. However, the cT downstaging (OR = 0.862, 95% CI: 0.241-3.086, P = 0.819) and cN downstaging (OR = 0.937, 95% CI: 0.372-2.360, P = 0.890) for patients in the neoadjuvant subgroup failed to lower PELLNR. The predominant recurrence field type was single-field.

Conclusions

Thoracic ESCC patients with lymph node recurrence within one year delivered poor outcomes, with advanced stages (pT3-4/pN2-3) and upper thoracic location considered risk factors for early recurrence.

Subjective factors affecting prognosis of 469 patients with esophageal squamous cell carcinoma: a retrospective cohort study of endoscopic screening

BACKGROUND

To date, no in-depth studies have focused on the impact of various clinical characteristics of esophageal squamous cell carcinoma (ESCC), including its association with subjective symptoms, on patient prognosis. We aimed to investigate the clinical factors that affect the prognosis of patients with ESCC and to clarify how subjective symptoms are related to prognosis.

METHODS

We retrospectively evaluated the clinical records of 503 consecutive patients with ESCC from April 2011 to December 2019. Six established prognostic factors for ESCC (body mass index, alcohol drinking, cigarette smoking, sex, clinical stage, and age) and subjective symptoms were used to subgroup patients and analyze survival differences. Next, the patients were divided into two groups: a symptomatic group and an asymptomatic group. In the symptomatic group, differences in the incidence of subjective symptoms according to tumor size, tumor location, macroscopic tumor type, and clinical stage were examined. Finally, subjective symptoms were divided into swallowing-related symptoms and other symptoms, and their prognosis was compared.

RESULTS

Multivariate Cox regression analysis identified sex [hazard ratio (HR) 1.778; 95% CI 1.004-3.149; p = 0.049], TNM classification (HR 6.591; 95% CI 3.438-12.63; p < 0.001), and subjective symptoms (HR 1.986; 95% CI 1.037-3.803; p = 0.0386) as independent risk factors for overall survival. In the symptomatic group, the mean time from symptom onset to diagnosis was 2.4 ± 4.3 months. The incidence of subjective symptoms differed by clinical stage, and the prognosis of patients with swallowing-related symptoms was significantly worse than that of patients with other symptoms.

CONCLUSION

The results of this study suggest that screening by upper gastrointestinal endoscopy, independent of subjective symptoms (especially swallowing-related symptoms), may play an important role in the early detection and improvement of prognosis of ESCC, although further validation in a large prospective study is needed.

Intraoperative hypotension is not associated with adverse short-term postoperative outcomes after esophagectomy in esophageal cancer patients

Background

The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied.

Methods

A prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastric anastomosis for esophageal cancer. Intraoperative hypotension (IOH), defined as systolic blood pressure (SBP) < 90 mm Hg lasting more than 5 min, was recorded. Patients’ 30 days post-operative composite outcome of mortality, anastomotic leak, and prolonged hospital stay were analyzed as outcome variables.

Result

A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. The mean duration of the surgery was 208 min. Intraoperative mean low SBP was 80 mmHg while the lowest record was 55 mmHg. IOH occurred in 51% (n = 29) of patients. Anastomotic leak occurred in 7% (n = 4) (OR 1.2, 95% CI 0.26–6.3; p = 0.76). In-hospital mortality was 5% (n = 3) (OR 1.44, 95% CI 0.22–9.3; p = 0.7) and 33% (n = 18) had prolonged hospital stay (OR 0.53, 95% CI 0.14–1.9; p = 0.34). The overall anastomotic leak rate was 13% (n = 7). Multivariate analysis (logistic regression model) showed SBP < 90 mmHg for more than 5 min was not significantly associated either with individual or composite outcomes of mortality, anastomotic leak, and prolonged hospital stay (AOR 1.06, 95% CI 0.98–1.14; p = 0.16)

Conclusion

In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association with composite adverse outcomes of mortality, anastomotic leak, and prolonged hospital stay.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

One Decade of Experience with Endoscopic Stenting for Intrathoracic Anastomotic Leakage after Esophagectomy: Brilliant Breakthrough or Flash in the Pan?

Management of intrathoracic anastomotic leakage after esophagectomy by means of endoscopic stent insertion has gained wide acceptance as an alternative to surgical reintervention. Between January 2004 and March 2013 all patients who underwent esophagectomy at a German high-volume center for esophageal surgery were included in this retrospective study. The study comprises 356 patients. Anastomotic leakage occurred in 49 cases. There were no significant differences in age, American Society of Anesthesiologists (ASA) score, or frequency of neoadjuvant therapy between cases with and without leak. However, leak patients sustained significantly more often postoperative pneumonia, pleural empyema, sepsis, and acute renal failure. Moreover, leak victims had higher odds for fatal outcome (16 of 49 vs 33 of 307; odds ratio, 5.94; 95% confidence interval, 2.65 to 13.15; P < 0.0001). The leakage was amendable by endoscopic stenting in 29 cases, whereas rethoracotomy was mandatory in 20 patients. Between stent and rethoracotomy cases, we observed no significant differences in age, ASA score, neoadjuvant therapy, occurrence of pneumonia, pleural empyema, or tracheostomy rate. Rethoracotomy patients sustained more often sepsis (16 of 20 vs 14 of 29; P = 0.04) and acute renal failure (nine of 20 vs four of 29; P = 0.02) as expression of more severe septic disease. Nevertheless, there was no significant difference in mortality (seven of 29 vs nine of 20; P = 0.21). Furthermore, we observed three cases of stent-related aortic erosion with peracute death from exsanguination. Despite being the preferred treatment option, endoscopic stenting was only feasible in approximately 60 per cent of all intrathoracic leaks. The results are marred by the occurrence of deadly vascular erosion. Therefore, individualized strategies should be preferred to a general recommendation for endoscopic stenting.

Current Outcome of Esophagectomy in the Very Elderly: Experience of a German High-volume Center

Operative management of esophageal carcinoma in the very elderly is still controversially discussed. It is not yet decided whether the risk warrants the procedure. The aim of this study is to analyze the outcome of esophagectomy for esophageal cancer in the very elderly. Factors influencing the clinical course and determining the outcome are identified. A retrospective study 292 consecutive cases of esophagectomy for nonmetastatic esophageal cancer at a German tertiary referral hospital between 2004 and 2011 were reviewed. Two age groups (75 years or older and younger than 75 years) were formed. The mean age was 63 years. Altogether 45 patients were 75 years or older. There were no significant differences in American Society of Anesthesiologists score, operative procedure, or in the frequency of anastomotic leakage between the age groups. However, very elderly patients with anastomotic leak had an eight times higher risk for fatal outcome than the very elderly without leak (odds ratio [OR], 8.54; 95% confidence interval [CI], 1.0 to 112.18; P = 0.025). Moreover, the odds for postoperative death were five times higher in very elderly patients with leak than in younger patients sustaining anastomotic leakage (OR, 5.67; 95% CI, 0.67 to 73.83; P = 0.046). In general, the very elderly had a three times higher risk for a fatal outcome (OR, 3.30; 95% CI, 1.37 to 7.86; P = 0.008). In-hospital mortality of the very elderly was 11 out of 45 compared with 8 per cent (20 of 247) in the younger group. Fatal outcome was more often caused by medical (seven) than by surgical complications (four cases). The remaining 34 patients recovered well. Very elderly patients undergoing esophagectomy have no elevated risk for occurrence of surgical complications, whereas the mortality of these complications is much higher. Improved outcome is achievable by timely management of postoperative surgical as well as medical complications. Notwithstanding the increased mortality, esophagectomy should be considered in thoroughly selected very elderly patients with curable esophageal carcinoma.

Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process

Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.

Nutritional benefit of laparoscopic jejunostomy during neoadjuvant chemotherapy for obstructing esophageal cancer

Neoadjuvant chemotherapy (NAC) confers a survival benefit in esophageal carcinoma, but it is difficult to perform in patients who cannot receive enteral feeding due to an esophageal obstruction. In the current study, the nutritional benefit of laparoscopic jejunostomy (Lap-J) was evaluated in patients with NAC for obstructing esophageal cancer. A total of 91 patients with esophageal cancer who received NAC between 2009 and 2017 were included in the present study. Lap-J was performed prior to NAC in 15 patients (16.5%) with an obstructing tumor. Patients with NAC without Lap-J were used as the control group (n=76). Nutritional parameters and surgical outcomes of the two groups were compared retrospectively. In the patients with Lap-J, 14 of the 15 patients (93.3%) did not experience any procedure-associated complications. No mortalities were associated with Lap-J. Significant decreases in total serum protein, albumin, hemoglobin concentrations and prognostic nutritional index (PNI) occurred following NAC in the control but not in the Lap-J group. Serum albumin and the improved modified Glasgow prognostic score increased significantly after NAC in the Lap-J group but not in the control group. In conclusion, perioperative nutritional support with Lap-J was safe and effective in patients with NAC for obstructing esophageal cancer.

Diagnostic value of surveillance 18F-fluorodeoxyglucose PET/CT for detecting recurrent esophageal carcinoma after curative treatment

PURPOSE

Esophageal carcinoma recurs within two years in approximately half of patients who receive curative treatment and is associated with poor survival. While ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a reliable method of detecting recurrent esophageal carcinoma, in most previous studies FDG PET/CT scans were performed when recurrence was suspected. The aim of this study was to evaluate FDG PET/CT as a surveillance modality to detect recurrence of esophageal carcinoma after curative treatment where clinical indications of recurrent disease are absent.

METHODS

A total of 782 consecutive FDG PET/CT studies from 375 patients with esophageal carcinoma after definitive treatment were reviewed. Abnormal lesions suggestive of recurrence on PET/CT scans were then evaluated. Recurrence was determined by pathologic confirmation or other clinical evidence within two months of the scan. If no clinical evidence for recurrence was found at least 6 months after the scan, the case was considered a true negative for recurrence.

RESULTS

The diagnostic sensitivity and specificity of PET/CT for detecting recurrent esophageal carcinomas were 100% (64/64) and 94.0% (675/718), respectively. There were no significant differences in the diagnostic performance of PET/CT for detecting recurrence according to initial stage or time between PET/CT and curative treatments. Unexpected second primary cancers were detected by FDG PET/CT in seven patients.

CONCLUSIONS

Surveillance FDG PET/CT is a useful imaging tool for detection of early recurrence or clinically unsuspected early second primary cancer in patients with curatively treated esophageal carcinoma but without clinical suspicion of recurrence.

Delayed emptying of the gastric conduit after esophagectomy

With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.

Influence of Neoadjuvant Therapy on Poor Long-Term Outcomes of Postoperative Complications in Patients with Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

BACKGROUND

Postoperative complications have a negative impact on overall survival after esophagectomy because systemic inflammation may induce residual cancer cell growth. A solution that could suppress micrometastasis is neoadjuvant therapy; however, to date, no study has shown that neoadjuvant therapy suppresses proliferation of cancer cells due to postoperative complications after esophagectomy. The aim of this study is to investigate the influence of neoadjuvant therapy on poor long-term outcomes of postoperative complications in patients with esophageal carcinoma.

PATIENTS AND METHODS

In total, 431 patients who underwent esophagectomy for esophageal squamous cell carcinoma were included in this study. We investigated the relationship between complications, such as pneumonia, and long-term oncologic outcomes with and without neoadjuvant therapy.

RESULTS

Among the patients, the 3-year overall survival (OS) rate was 69.5% and the disease-free survival (DFS) rate was 59.0%. The patients were categorized into two groups: the neoadjuvant therapy (+) group (n = 217) and neoadjuvant therapy (-) group (n = 214). Among patients not undergoing neoadjuvant therapy, patients with pneumonia or pyothorax had significantly poorer OS and DFS than patients without these complications. However, among patients undergoing neoadjuvant therapy, there were no significant differences in long-term outcomes, regardless of presence of complications. On multivariate analysis, pneumonia (p = 0.003), pyothorax (p < 0.001), and chylothorax (p = 0.002) were identified as predictors of death in the neoadjuvant therapy (-) group.

CONCLUSION

The negative impact of postoperative complications on long-term prognoses can be reduced by performing neoadjuvant therapy in patients with esophageal carcinoma.

Combined surgical treatment of esophageal cancer and coronary heart diseases in elderly patients

OBJECTIVE

The co-incidence of esophageal cancer and coronary heart disease (CHD) is increasing in elderly patients. This study was carried out to analyze the efficiency and safety of simultaneous esophagectomy and cardiac surgery in a selected group of elderly patients.

METHODS

Prospective database for coexistency of severe CHD and esophageal or esophageal-gastric junction cancer was firstly reviewed. Twenty-two patients undergoing combined surgical interventions, including first beating-heart coronary artery bypass grafting (off-pump CABG) and then esophagectomy, were involved as group A. Then, 44 patients undergoing isolated esophagectomy were selected as group B using the propensity score matching method. Data including clinic pathological characteristics and postoperative outcomes were investigated. Kaplan-Meier analysis was used.

RESULTS

The surgical procedure was performed through left lateral thoracotomy in all patients, except one patient in group A who received median sternotomy and left lateral thoracotomy. The operation time and blood loss were both more in group A, as a result of two operations performed at one session. Patients in both groups were followed up from 1.3 to 78.3 months. No significant between-group was found in overall survival or relapse-free survival.

CONCLUSION

The risk of simultaneous esophagectomy and cardiac surgery is not high. Despite certain differences in clinical indicators between groups, the safety of simultaneous procedures in group A is evident.

TRIAL REGISTRATION

ChiCTR 1800014498 . Registered 17 January 2018.

Regenerative medicine for the esophagus

Advances in tissue engineering techniques have made it possible to use human cells as biological material. This has enabled pharmacological studies to be conducted to investigate drug effects and toxicity, to clarify the mechanisms underlying diseases, and to elucidate how they compensate for impaired organ function. Many researchers have tried to construct artificial organs using these techniques, but none has succeeded in growing a whole organ. Unlike other digestive organs with complicated functions, such as the processing and absorption of nutrients, the esophagus has the relatively simple function of transporting content, which can be replicated easily by a substitute. In regenerative medicine, various combinations of materials have been applied, including scaffolding, cell sources, and bioreactors. Exciting results of tissue engineering techniques for the esophagus have been reported. In animal models, replacing full-thickness and full-circumferential defects remains challenging because of stenosis and leakage after implantation. Although many reports have manipulated various scaffolds, most have emphasized the importance of both epithelial and mesenchymal cells for the prevention of stenosis. However, the results of repair of partial full-thickness defects and mucosal defects have been promising. Two successful approaches for the replacement of mucosal defects in a clinical setting have been reported, although in contrast to the many animal models, there are few pilot studies in humans. We review the recent results and evaluate the future of regenerative medicine for the esophagus.

Disparities in major surgery for esophagogastric cancer among hospitals by case volume

Background

The purpose of this study was to characterize disparities among centers performing major surgery for esophageal or gastric cancer stratified by case volume.

Methods

The National Cancer Data Base (NCDB) was queried for cases of esophagectomy or total gastrectomy. Centers were compared based on number of cases during 2004-2013: low volume [1-99], middle [100-200], and high [>200].

Results

For esophagectomy, 17,547 patients were included; 73.5% were treated in low volume centers, 14.6% in middle, and 11.9% in high. For gastrectomy, 20,059 patients were included, with 87.5%, 8.3%, and 4.3%, respectively. Patients treated at low volume centers were more likely to be of racial/ethnic minorities, uninsured, and have lower socioeconomic status. Overall survival (OS) was superior for patients treated at high volume centers. On multivariable analysis for either procedure, a higher number of disparate factors was identified in the low and middle volume centers compared to the high volume centers, which were associated with poorer OS.

Conclusions

This study identified higher numbers of disparate patient factors associated with low/middle volume centers compared to high volume centers, which were associated with worse OS, and further makes the case for performance of esophagectomy and total gastrectomy at high volume centers.

External validation of the NUn score for predicting anastomotic leakage after oesophageal resection

Early detection of anastomotic leakage (AL) after oesophageal resection for malignancy is crucial. This retrospective study validates a risk score, predicting AL, which includes C-reactive protein, albumin and white cell count in patients undergoing oesophageal resection between 2003 and 2014. For validation of the NUn score a receiver operating characteristic (ROC) curve is estimated. Area under the ROC curve (AUC) is reported with 95% confidence interval (CI). Among 258 patients (79.5% male) 32 patients showed signs of anastomotic leakage (12.4%). NUn score in our data has a median of 9.3 (range 6.2–17.6). The odds ratio for AL was 1.31 (CI 1.03–1.67; p = 0.028). AUC for AL was 0.59 (CI 0.47–0.72). Using the original cutoff value of 10, the sensitivity was 45.2% an the specificity was 73.8%. This results in a positive predictive value of 19.4% and a negative predictive value of 90.6%. The proportion of variation in AL occurrence, which is explained by the NUn score, was 2.5% (PEV = 0.025). This study provides evidence for an external validation of a simple risk score for AL after oesophageal resection. In this cohort, the NUn score is not useful due to its poor discrimination.

Survival predictors associated with signet ring cell carcinoma of the esophagus (SRCCE): A population-based retrospective cohort study

Purpose

Signet ring cell carcinoma of the esophagus (SRCCE) is an uncommon tumor associated with significant morbidity and mortality. There is still no consensus regarding cut-off values for tumor size, age and optimal treatment for SRCCE. Thus, we elucidated the current survival outcomes of patients with SRCCE and analyzed factors associated with prognosis.

Methods

A retrospective cohort study based on the SEER (The Surveillance, Epidemiology, and End Results) program database was conducted. We identified 537 patients (461 men and 76 women) newly diagnosed with SRCCE between January 2004 and December 2014. A multivariate Cox proportional hazards model was utilized to measure the mortality-associated risk factors in patients with SRCCE after adjusting for various variables.

Results

The 1-, 2- and 5-year disease-specific mortalities (DSM) were 51.6%, 67.6%, and 78.4%, respectively, and the median survival time was 12.0 months. The factors correlated with mortality hazard were marital status (unmarried versus married, Hazard Ratio (HR) = 1.443), tumor size (≥ 5 cm versus < 5 cm, HR = 1.444), tumor grade (high grade versus low grade, HR = 3.001), condition of primary tumor (T4 versus T1, HR = 2.178), regional lymph node metastasis (N1 versus N0, HR = 1.739), further metastasis (M1 versus M0, HR = 1.951) and chemotherapy (receiving chemotherapy versus no chemotherapy, HR = 0.464).

Conclusions

The contemporary 5-year DSM was 78.4%. Being unmarried, having a tumor size ≥ 5 cm, a high tumor grade, a score of T4 for tumor invasion of adjacent organs, a score of N1 for regional lymph node metastasis, a score of M1 for distant metastasis and no chemotherapy were independent predictors of high DSM.

Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.

Adjuvant Therapy for a Microscopically Incomplete Resection Margin after an Esophagectomy for Esophageal Squamous Cell Carcinoma

Purpose: To investigate the prognosis of esophageal squamous cell carcinoma with a microscopically incomplete (R1) resection margin following an esophagectomy, as well as the impact of adjuvant treatment on survival. Methods: Data obtained from 124 patients with R1-resected ESCC were reviewed. The impact of clinicopathological factors and adjuvant treatment on the overall survival, locoregional recurrence, and distant recurrence were explored. Results: For a median follow-up time of 16.8 months, the median overall survival of 124 patients was 25.6 months. The 1, 3, and 5-year overall survival rates were 75.6%±4.0%, 35.9%±5.1%, and 23.2%±5.0%, respectively. Adjuvant therapy was administered in 78 patients. In the univariate analyses, patients with a pN0 stage (log rank, p=0.028) and adjuvant chemotherapy (log rank, p=0.032) exhibited more favorable overall survival. In the multivariate analyses, the pN stage (HR=2.192, p=0.004) and adjuvant chemotherapy (HR=0.032, p=0.004) were independent prognostic factors for overall survival. Locoregional recurrence was the main failure pattern after R1 resection. The pN stage (HR=2.567, p=0.009) and adjuvant radiotherapy (HR=0.278, p=0.000) were independent prognostic factors for locoregional recurrence. Conclusion: In R1-resected esophageal squamous cell carcinoma, adjuvant radiotherapy reduced locoregional recurrence; however, it did not improve overall survival. Adjuvant chemotherapy demonstrated benefits for overall survival. The pN stage was an independent prognostic factor for locoregional recurrence and overall survival.

Simple preoperative risk scale accurately predicts perioperative mortality following esophagectomy for malignancy

Surgery remains one of the major treatment options available to patients with esophageal cancer, with high mortality in certain cohorts. The aim of this study was to develop a simple preoperative risk scale based on patient factors, hospital factors, and tumor pathology to predict the risk of perioperative mortality following esophagectomy for malignancy. The Nationwide Inpatient Sample database was used to create the risk scale. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using International Classification of Diseases, 9th edition codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regressions were used to define a predictive model of perioperative mortality and to create a simple risk scale. From 1998 to 2011, a total of 23 751 patients underwent esophagectomy. The observed overall perioperative mortality rate for this cohort was 7.7%. Minimally invasive techniques, and operations performed in higher volume centers were protective, whereas increasing age, comorbidities and diagnosis of squamous cell carcinoma were independent predictors of mortality. Based on this population, a risk scale from 0-16 was created. The calibration revealed a good agreement between the observed and risk scale-predicted probabilities. A set of sensitivity/specificity analyses was then performed to define normal (score 0-7) and high risk (score 8-16) patients for clinical practice. Mortality in patients with a score of 0-7 ranged from 1.3-7.6%, compared with 10.5-34.5% in patients with a score of 8-16. This simple preoperative risk scale may accurately predict the risk of perioperative mortality following esophagectomy for malignancy and can be used as a clinical tool for preoperative counseling.

Systematic review of patient-reported outcome measures in the surgical treatment of patients with esophageal cancer

Esophageal cancer is currently the eighth most common cancer worldwide. Improvements in operative techniques and neoadjuvant therapies have led to improved outcomes. Resection of the esophagus carries a high risk of severe complications and has a negative impact on health-related quality of life (QOL). The aim of this study was to assess which patient-reported outcome measures (PROMs) are used to measure QOL after esophagectomy for cancer. A comprehensive search of original articles was conducted investigating QOL after surgery for esophageal carcinoma. Two authors independently selected relevant articles, conducted clinical appraisal, and extracted data (PJ and JS). Out of 5893 articles, 58 studies were included, consisting of 41 prospective and 17 retrospective cohort studies, including a total of 6964 patients. These studies included 11 different PROMs. The existing PROMs could be divided into generic, symptom-specific, and disease-specific questionnaires. The European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 30 (QLQ C-30) along with the EORTC QLQ-OESophagus module OES18 was the most widely used; in 42 and 32 studies, respectively. The EORTC and the Functional Assessment of Cancer Therapy (FACT) questionnaires use an oncological module and an organ-specific module. One validation study was available, which compared the FACT and EORTC, showing moderate to poor correlation between the questionnaires. A great variety of PROMs are being used in the measurement of QOL after surgery for esophageal cancer. A questionnaire with a general module along with a disease-specific module for assessment of QOL of different treatment modalities seem to be the most desirable, such as the EORTC and the FACT with their specific modules (EORTC QLQ-OES18 and FACT-E). Both are developed in different treatment modalities, such as in surgical patients. With regard to reproducibility of current results, the EORTC is recommended.

Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample

BACKGROUND

The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume.

METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology.

RESULTS

A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups.

CONCLUSION

No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.

Esophagectomy: Comparison of Short-Term Outcomes between Single-versus Two-Team Approach

Literature about combining expertise of two specialties in esophageal cancer surgery is limited. We present the experience at a single institute comparing single-team (ST) versus two-team (TT) approach combining thoracic and abdominal surgeons. This is a retrospective study from a single tertiary care center. Data were collected from electronic medical records. Patients undergoing esophagectomy for esophageal cancer from November 2006 until August 2014 were included. The primary outcome measured was 30-day postoperative morbidity, secondary outcomes measured were operative time, intraoperative blood loss, and 30-day mortality. Results are reported as mean with an interquartile range. Forty-nine patients underwent esophagectomy by an ST and 51 patients by TT. Patient demographics, tumor characteristics, stage, pathology, and use of neoadjuvant therapy were comparable between groups. Charlson comorbidity index was significantly higher in TT group [3 (2, 4) vs 2 (2, 3), P = 0.02]. The TT group had a significantly shorter operative time compared to the ST group [304 (252,376) minutes vs 438 (375, 494] minutes, P < 0.0001). Intraoperative blood loss was 300 (200, 550) mL for the TT group and 250 (200,400) mL for the ST group ( P = 0.29). There was no difference in 30-day postoperative morbidity (68.6% for TT, 59.2% for ST, P = 0.32) and mortality (2% each, P = 1) between the two groups. In conclusion, the operative time by the TT approach was significantly shorter than the ST approach with comparable postoperative morbidity and mortality. Long-term follow-up is needed to study this approach's effect on long-term survival.

Prognostic and clinical impact of sarcopenia in esophageal squamous cell carcinoma

Recently, depletion of skeletal muscle mass (sarcopenia) has been linked to poor prognosis in several types of cancers, but has not been investigated in esophageal squamous cell carcinoma (ESCC). This retrospective study investigates the relationship between sarcopenia and clinical outcome in ESCC patients treated by surgical resection or definitive chemoradiation therapy (dCRT). The study was retrospectively conducted in a single academic hospital in Kumamoto, Japan, and involved 325 ESCC patients (256 surgical cases and 69 dCRT cases) treated between April 2005 and April 2011. Skeletal muscle mass was quantified by radiologic measures using standard computed tomography scans. The skeletal muscle tissue in the 325 ESCC patients was distributed as follows: mean: 47.10; median: 46.88; standard deviation (SD): 7.39; range: 31.48-71.11; interquartile range, 46.29-47.90. Skeletal muscle tissue was greater in male patients than in female patients (P < 0.0001), but was independent of other clinical and tumor features. Sarcopenia was not significantly associated with overall survival (log rank P = 0.54). Lymph node involvement significantly altered the relationship between sarcopenia and survival rate (P for interaction = 0.026). Sarcopenia significantly reduced the overall survival of patients without lymph node involvement (log rank P = 0.035), but was uncorrelated with overall survival in patients with lymph involvement (log rank, P = 0.31). The anastomosis leakage rate was significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.032), but other surgical complications did not significantly differ between the two groups. Sarcopenia in ESCC patients without lymph node involvement is associated with poor prognosis, indicating sarcopenia as a potential biomarker for identifying patients likely to experience an inferior outcome. Moreover, sarcopenia was associated with anastomosis leakage but no other short-term surgical outcome.

Which factors are associated with extremely short-term survival after surgery in patients with esophageal squamous cell carcinoma?

AIMS

Esophageal squamous cell carcinoma (ESCC) is associated with a short median survival and low cure rates. The postoperative survival time of some patients with ESCC is extremely short. It is important to understand risk factors in subsets of patients associated with extremely short-term survival. The standard factors such as T and N stage, which are predictive of actuarial survival, become less important as patients live for ≤1 year. However, the prevalence of these factors in these patient populations has not been well documented. We evaluated factors predictive of ≤1 year survival in this research.

METHODS

We analyzed 1596 patients underwent esophagectomy for ESCC retrospectively. The demographic and clinicopathologic characteristics were compared between patients who died within 1 year of esophagectomy and patients who survived more than 1 year after esophagectomy.

RESULTS

Univariate analysis showed significant differences between the two groups regarding gender, weight loss, comorbidity, neoadjuvant treatment, completeness of resection, pathological T stage, pathological N stage, histologic grade, the number of metastatic lymph nodes, postoperative complications, postoperative pulmonary infection and postoperative hospital stay. Based on logistic regression analysis, significant factors associated with extremely short-term survival were male gender, incomplete tumor resection, higher pathological T stage, higher pathological N stage and postoperative pulmonary infection.

CONCLUSION

The independent positive predictors for extremely short-term survival are male gender, incomplete tumor resection and postoperative pulmonary infection besides higher pathological T stage and higher pathological N stage.

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

BACKGROUND

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.

RESULTS

From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05).

CONCLUSION

Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer

BACKGROUND

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections.

METHODS

The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure.

RESULTS

Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration.

CONCLUSION

Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems.

Postoperative complications do not affect long-term outcome in esophageal cancer patients

BACKGROUND

As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients.

METHODS

Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study.

RESULTS

SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival.

CONCLUSIONS

This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.

Preoperative airway colonization prior to transthoracic esophagectomy predicts postoperative pulmonary complications

PURPOSE

Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications.

METHODS

In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (<24 h, 24-72 h, >72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints.

RESULTS

In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p < 0.001), and a higher frequency of re-intubation (p < 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p < 0.0001).

CONCLUSION

PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.

Minimally invasive esophagectomy for esophageal cancer - results of surgical therapy

Introduction

The indication for minimally invasive esophagectomy (MIE) in esophageal cancer has an increasing tendency.

Aim

To present our cohort of patients operated on between 2006 and 2012.

Material and methods: A single centre study of 106 consecutive esophagectomies performed for esophageal cancer by a minimally invasive approach in 79 patients was performed. Transhiatal laparoscopic esophagectomy (THLE) was performed in 66 patients, transthoracic esophagectomy (TTE) in 13 patients, with histological findings of squamous cell carcinoma in 28 and adenocarcinoma in 51 patients.

Results

The MIE was completed in 76 (96.2%) patients. In cases of TTE, the operation was converted to an open procedure in 3 cases. Operation time ranged from 225 to 370 min (average 256 min). The number of lymph nodes removed was 7–16 (11 on average). The postoperative course was without any complications in 54 (68.3%) patients. Respiratory complications were observed in 14 (17.7%) patients (9 following THLE, 5 following TTE). Other serious complications included acute myocardial infarction (1 patient) and necrosis of the gastroplasty (1 patient). Anastomotic dehiscence was observed in 8 patients, left recurrent laryngeal nerve paralysis in 8 patients, intra-abdominal abscesses in 2 patients, and pleural empyema in 1 case. The overall morbidity of patients operated on by MIE was 31.6%. Thirty-day mortality was 10.1%.

Conclusions

The MIE belongs to the therapeutic portfolio of surgical procedures performed for esophageal cancer. Successful performance requires erudition of the surgical team in both minimally invasive procedures as well as in classical surgical treatment of esophageal cancer; therefore centralization of patients is imperative.

[Lymph node involvement in œsophageal cancer: surgical approach]

Lymph node invasion is an early event in the oesophageal carcinogenesis and represents the main prognostic factor in the curative setting. Even though the primacy of surgical resection has been challenged by the definitive radiochemotherapy for locally advanced squamous cell carcinomas of the oesophagus, surgery is now again a gold standard, in combination with (radio)chemotherapy, to improve locoregional disease control and long term survival. Surgery, especially lymphadenectomy, has consequently to be standardized through quality criteria. Lymph node stations invaded in œsophageal and junctional cancers, lymphadenectomy, and its impact on outcomes are discussed in this review based on the highest level of evidence published data.

Replacement of the esophagus with fascial flap-wrapped allogenic aorta

BACKGROUND

Segmental replacement of the esophagus (SRE) is challenging. Allogenic aorta (AA) has shown promising remodeling abilities when used as an esophageal substitute. The aim of this study was to evaluate the feasibility and results of esophageal replacement with fascial flap-wrapped AA segments in a novel rabbit model.

MATERIALS AND METHODS

Seven Geant des Flandres rabbits and one New Zealand rabbit served as thoracic aorta donors, and 25 New Zealand rabbits were used as recipients. One to 3 wk before esophageal replacement either cryopreserved or fresh thoracic aortic segments were wrapped in thoracic wall fascia to generate revascularization. In an attempt to optimize the model, step-by-step modifications concerning perioperative and postoperative management of the recipients were made as results accumulated. Microscopic evaluation was focused on the viability of aortic segments and neoangiogenesis originating from the fascia.

RESULTS

Survival after SRE was poor. Most recipients died within 1 wk, mainly from upper digestive tract hypomotility. Microscopically, AAs were severely necrosed. In one recipient sacrificed on day 16, the edges of the graft became evanescent. In these areas, esophageal reepithelialization directly covered the fascia, in which unexpected smooth muscle cells were found, suggestive of the first stages of esophageal remodeling of the graft.

CONCLUSIONS

Results for SRE using fascial-wrapped AAs in rabbits were disappointing. The transposition of this approach to larger animals might result in longer survival, increasing the possibility for more complete graft remodeling.

Seamless vascularized large-diameter tubular collagen scaffolds reinforced with polymer knittings for esophageal regenerative medicine

A clinical demand exists for alternatives to repair the esophagus in case of congenital defects, cancer, or trauma. A seamless biocompatible off-the-shelf large-diameter tubular scaffold, which is accessible for vascularization, could set the stage for regenerative medicine of the esophagus. The use of seamless scaffolds eliminates the error-prone tubularization step, which is necessary when emanating from flat scaffolds. In this study, we developed and characterized three different types of seamless tubular scaffolds, and evaluated in vivo tissue compatibility, including vascularization by omental wrapping. Scaffolds (luminal Ø ∼ 1.5 cm) were constructed using freezing, lyophilizing, and cross-linking techniques and included (1) single-layered porous collagen scaffold, (2) dual-layered (porous+dense) collagen scaffold, and (3) hybrid scaffold (collagen+incorporated polycaprolacton knitting). The latter had an ultimate tensile strength comparable to a porcine esophagus. To induce rapid vascularization, scaffolds were implanted in the omentum of sheep using a wrapping technique. After 6 weeks of biocompatibility, vascularization, calcification, and hypoxia were evaluated using immunohistochemistry. Scaffolds were biocompatible, and cellular influx and ingrowth of blood vessels were observed throughout the whole scaffold. No calcification was observed, and slight hypoxic conditions were detected only in the direct vicinity of the polymer knitting. It is concluded that seamless large-diameter tubular collagen-based scaffolds can be constructed and vascularized in vivo. Such scaffolds provide novel tools for esophageal reconstruction.

Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis

BACKGROUND

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.

METHODS

Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.

RESULTS

No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005).

CONCLUSIONS

A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.

Esophagectomy for cancer of the esophagus. A regional cancer centre experience

Surgery is an important component of treatment for patients with resectable cancer of the mid and lower third of the esophagus. There are many controversies associated with esophagectomy. We share our experience with esophagectomy for cancer of the mid and lower third of the esophagus. Between January 2007 and December 2011, 210 patients with cancer of the esophagus underwent surgery. The patients' pre and intra- operative factors, morbidities and mortality were noted and studied. Transhiatal esophagectomy was done in 175 patients and right transthoracic esophagectomy was done in 35 patients. The most common location of the tumor was lower third and most common histopathology was squamous cell carcinoma. There were 5 in-hospital deaths (2.4 %) and the common morbidities encountered were respiratory (30 %), anastomotic leak (5 %) and anastomotic stricture (15 %). The morbidity was higher in the transthoracic group. Our R0 resection rate was 89 %. Esophagectomy can be accomplished with acceptable morbidity in the management of patients with oesophageal cancer. We attribute the favourable results to the high volume at our centre, surgical expertise, good patient selection and performance of the anastomosis in the neck.

Metabolomic profiling of oesophago-gastric cancer: a systematic review

AIMS

This review aims to identify metabolomic biomarkers of oesophago-gastric (OG) cancer in human biological samples, and to discuss the dominant metabolic pathways associated with the observed changes.

METHODS

A systematic review of the literature, up to and including 9th November 2012, was conducted for experimental studies investigating the metabolomic profile of human biological samples from patients with OG cancer compared to a control group. Inclusion criteria for analytical platforms were mass spectrometry or nuclear magnetic resonance spectroscopy. The QUADAS-2 tool was used to assess the quality of the included studies.

RESULTS

Twenty studies met the inclusion criteria and samples utilised for metabolomic analysis included tissue (n = 11), serum (n = 8), urine (n = 1) and gastric content (n = 1). Several metabolites of glycolysis, the tricarboxylic acid cycle, anaerobic respiration and protein/lipid metabolism were found to be significantly different between cancer and control samples. Lactate and fumurate were the most commonly recognised biomarkers of OG cancer related to cellular respiration. Valine, glutamine and glutamate were the most commonly identified amino acid biomarkers. Products of lipid metabolism including saturated and un-saturated free fatty acids, ketones and aldehydes and triacylglycerides were also identified as biomarkers of OG cancer. Unclear risk of bias for patient selection was reported for the majority of studies due to the lack of clarity regarding patient recruitment.

CONCLUSION

The application of metabolomics for biomarker detection in OG cancer presents new opportunities for the purposes of screening and therapeutic monitoring. Future studies should provide clear details of patient selection and develop metabolite assays suitable for progress beyond phase 1 pre-clinical exploratory studies.

The short-term outcome in esophagogastric junctional adenocarcinoma patients receiving total gastrectomy: laparoscopic versus open gastrectomy--a retrospective cohort study

OBJECTIVE

This study aimed to compare the quality of life in Siewert type II esophagogastric junctional adenocarcinoma patients receiving either laparoscopic total gastrectomy or open total gastrectomy.

METHODS

From Sep 1, 2008 to May 1, 2012, totally 204 consecutive patients with Siewert type II esophagogastric junctional adenocarcinoma were involved in this retrospective study. Patients were assigned to receive either laparoscopic total gastrectomy or open total gastrectomy. Details concerning the postoperative outcomes and the quality of life questionnaire were collected and compared.

RESULTS

Totally 104 patients were involved in the open gastrectomy group and 100 in the laparoscopic gastrectomy group. No differences were noted between the groups in demographics, blood loss, anastomotic leak, anastomotic stricture, hospital stay, reoperation and in-hospital mortality. Totally 188 cases of patients (92.16%) responded to the questionnaire measures during the entire follow-up period, including 93 (93%) in the laparoscopic group and 95 (91.35%) in the open group. The score of every scale and item in laparoscopic group improved much more quickly comparing with the open group, suggesting that patients in laparoscopic group recovered much more quickly than those in open group.

CONCLUSIONS

Laparoscopic total gastrectomy could lead to a significant improvement of the short-term benefits for patients with esophagogastric junctional adenocarcinoma as compared with open group.

The impact of multimodality therapy of distal esophageal and gastroesophageal junction adenocarcinomas on treatment-related toxicity and complications

The benefit of multimodality therapy is clearly established for adenocarcinomas of the distal esophagus and gastroesophageal junction, but its impact on toxicity is not well defined. We reviewed data from prospective randomized trials to better define the risks of multimodality therapy. The rates of surgical mortality and complications range from 0% to 10% and 23% to 49%, respectively. Multimodality therapy increases acute toxicity. The rate of severe acute hematologic toxicity varies considerably between trials (3%-78%) and appears to be primarily attributable to chemotherapy. Common severe acute nonhematologic toxicities include esophagitis (16%-63%), infection (2%-30%), pain (3%-24%), and gastrointestinal (6%-60%) and cardiac (3%-19%) events. The individual contribution of each modality to nonhematologic toxicities is unclear, but toxicity is increased when adding radiosensitizing chemotherapy to radiotherapy. There is an acute decrease in quality of life with multimodality therapy; however, quality of life usually returns to, or exceeds, baseline by 12 months after therapy. Late toxicities are less well defined, but commonly include esophageal, pulmonary, and cardiac toxicities.

Gender differences in prognosis after esophagectomy for esophageal cancer

PURPOSE

The purpose of this study was to clarify the gender differences in the prognosis, as well as mortality and morbidity, of patients who have undergone esophagectomy for esophageal cancer.

METHODS

The clinical results of esophagectomy were compared between 975 male and 156 female patients with esophageal cancer.

RESULTS

The male to female ratios of cervical and thoracic esophageal cancer were 1.87 and 7.38, respectively (P < 0.01). The incidence of preoperative comorbidities was 32.4 and 17.4 %, respectively, and the rates of both tobacco and alcohol abuse were significantly lower in the females than in the males. The mortality rate was lower in the females (3.8 %) than in the males (5.7 %), although the differences were not significant. The overall survival was significantly better in the female than in the male patients (P = 0.039). The 5- and 10-year overall survival rates were 32.6 and 20.5 % in the males and 39.5 and 32.5 % in the females, respectively. A multivariate analysis revealed gender to be an independent prognostic factor. However, no significant differences were recognized in disease-specific survival.

CONCLUSIONS

These results suggest that the prognosis of females with esophageal cancer is better than that of males after esophagectomy, most likely due to multiple clinical factors, such as a more favorable lifestyle and general status.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Lymph node invasion might have more prognostic impact than R status in advanced esophageal adenocarcinoma

BACKGROUND

Advanced esophageal adenocarcinomas are associated with 5-year survival rates ranging from 14% to 35%. Nodal status and tumor clearance are the main prognostic factors. However, their respective prognostic values have not been compared to date.

METHODS

Seventy consecutive patients with stage T3 adenocarcinomas of the esophagus or gastric cardia were retrospectively assessed. Neoadjuvant therapy was indicated in all cases. Prognostic values of R0 resection and nodal status were evaluated using univariate and multivariate analyses.

RESULTS

Neoadjuvant therapy was achieved in 62 patients, 41 with radiochemotherapy and 21 with perioperative chemotherapy. Transthoracic esophagectomy and transhiatal esophagectomy were performed in 54 and 15 patients, respectively. Clavien-Dindo grade III or IV complications occurred in 16 patients (23%). Two patients died in the hospital (3%). In univariate and multivariate analyses, nodal status was the main independent factor predicting overall survival; tumor clearance (R0 or R1) had less prognostic impact and was not statistically significant. Furthermore, R1 resection was a prognostic indicator for metastatic recurrence.

CONCLUSIONS

These results indicate that nodal status has more prognostic impact than R status in stage T3 adenocarcinomas of the esophagus or gastric cardia. Thus, local control in R1 patients by postoperative radiotherapy is not justified.