Outcomes assessment of the surgical management of esophageal cancer in younger and older patients. Ann Thorac Surg. 2012;94:1652-1658. [PMID: 23098941 DOI: 10.1016/j.athoracsur.2012.06.067]

Comparison of postoperative survival prognosis between early-onset and late-onset esophageal cancer: A Population-based study

The prognosis of non-distant metastatic early-onset esophageal cancer (EC) patients undergoing surgical treatment remains unclear, this study aims to compare the prognosis of early-onset and late-onset EC. Information on non-distant metastatic EC patients who underwent surgical treatment and were initially diagnosed between 2004 and 2015 was collected from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was used to balance the baseline differences between early-onset and late-onset EC patients. Univariate and multivariate Cox regression analyses were used to calculate hazard ratio (HR) and 95% confidence interval (CI). The Kaplan-Meier method and log-rank test were used to compare the overall survival (OS) between the two groups of patients. Atotal of 5320 EC patients were included, with 571 in the early-onset group and 4749 in the late-onset group. Multivariate Cox regression analysis showed that early-onset EC patients had better OS (HR = 0.732, 95% CI: 0.655-0.819, p<0.001). Using PSM analysis at a 1:1 ratio, we matched 557 early-onset EC patients with 557 late-onset EC patients. After matching, the multivariate Cox regression model still showed a favorable prognosis for early-onset EC (HR = 0.728, 95% CI: 0.630-0.842, p<0.001). Additionally, subgroup analysis indicated that early-onset EC patients had better long-term prognosis. Non-distant metastatic early-onset EC patients undergoing surgical treatment demonstrated better OS outcomes, confirmed by regression analysis and subgroup analysis in the matched cohort.

Survival outcomes fifteen years after minimally invasive esophagectomy

BACKGROUND AND OBJECTIVES

Minimally invasive esophagectomy (MIO) offers a less traumatic resection for cancer patients resulting in improved quality of life. Concerns about the oncological efficacy of the procedure and potential impact on survival may have limited its wider adoption. This study reports survival outcomes fifteen years after patients underwent a total MIO for esophageal cancer.

METHODS

A single-centre analysis of survival outcomes was conducted on all patients who underwent MIO between 2004 and 2010 and had completed at least 15-years follow-up. Actual overall survival (OS) and disease-free survival (DFS) were evaluated with the Kaplan-Meier method. The pattern of association of patient factors with survival was assessed with the Cox regression analysis.

RESULTS

A total of 121 patients underwent resection, with 4 (3.3%) in-patient deaths. With a median follow-up time of 15.2 years, the median OS was 41 months. At 15-years there were 20 survivors (17.1%), with numbers at 10 and 5 years being 34 (29.1%) and 45 (38.5%) respectively. Median DFS was 27 months, with 19 (16.2%) patient disease free at 15 years, and 32 (27.4%) and 38 (32.5%) at 10 and 5 years respectively. Predictors of poor survival were the intracorporeal fashioning of the gastric conduit, perioperative blood transfusions, advanced disease stage and recurrence.

CONCLUSIONS

Long term survival outcomes following MIO support its increasing recognition as the standard of care as for curative resection in esophageal cancer.

Frailty and long-term survival of patients with ovarian cancer: A systematic review and meta-analysis

Background

Frailty has been related with poor prognosis of various diseases, including ovarian cancer. We performed a systematic review and meta-analysis to evaluate the association between frailty and long-term survival of patients with ovarian cancer.

Methods

Relevant cohort studies were retrieved by search of PubMed, Embase, Cochrane's Library, and Web of Science electronic databases. Two authors independently performed literature search, data collection, and statistical analyses. A random-effect model incorporating the possible influence of heterogeneity was used to pool the results.

Results

Nine cohort studies including 2497 women with confirmed diagnosis of ovarian cancer contributed to the meta-analysis, and 536 (21.5%) of them were with high frailty. The median follow-up durations varied between 24 and 69 months. Compared to patients with low or non-frailty, OC patients with high frailty were associated with poor overall survival (risk ratio [RR]: 1.61, 95% confidence interval [CI]: 1.41 to 1.85, p < 0.001; I2 = 0%) and progression-free survival (RR: 1.51, 95% CI: 1.20 to 1.89, p < 0.001; I2 = 0%). Subgroup analyses according to study design, cancer stage, age of patients, scales for frailty evaluation, follow-up duration, and quality score of the included study showed consistent association between high frailty and poor overall survival in women with ovarian cancer (p for subgroup effects all < 0.05). After considering GRADE criteria for strength of the evidence, it was rated low for both the two outcomes.

Conclusion

High frailty may be an independent risk factor of poor survival in women with ovarian cancer. Evaluating frailty may be important for predicting the prognosis and determining the optimal anticancer treatments in women with ovarian cancer.

Systematic Review Registration

https://inplasy.com/, identifier INPLASY202290028.

Minimally invasive surgical techniques for oesophageal cancer and nutritional recovery: a prospective population-based cohort study

OBJECTIVES

To explore whether the minimally invasive oesophagectomy (MIE) or hybrid minimally invasive oesophagectomy (HMIE) are associated with better nutritional status and less weight loss 1 year after surgery, compared with open oesophagectomy (OE).

DESIGN

Prospective cohort study.

SETTING

All patients undergoing oesophagectomy for cancer in Sweden during 2013-2018.

PARTICIPANTS

A total of 424 patients alive at 1 year after surgery were eligible, and 281 completed the 1-year assessment. Of these, 239 had complete clinical data and were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was nutritional status at 1 year after surgery, assessed using the abbreviated Patient-Generated Subjective Global Assessment questionnaire. The secondary outcomes included postoperative weight loss at 6 months and 1 year after surgery.

RESULTS

Of the included patients, 78 underwent MIE, 74 HMIE while 87 patients underwent OE. The MIE group had the highest prevalence of malnutrition (42% vs 22% after HMIE vs 25% after OE), reduced food intake (63% vs 45% after HMIE vs 39% after OE), symptoms reducing food intake (60% vs 45% after HMIE vs 60% after OE) and abnormal activities/function (45% vs 32% after HMIE vs 43% after OE). After adjustment for confounders, MIE was associated with a statistically significant increased risk of reduced food intake 1 year after surgery (OR 2.87, 95% CI 1.47 to 5.61), compared with OE. Other outcomes were not statistically significantly different between the groups. No statistically significant associations were observed between surgical techniques and weight loss up to 1 year after surgery.

CONCLUSIONS

MIE was statistically significantly associated with reduced food intake 1 year after surgery. However, no differences were observed in weight loss between the surgical techniques. Further studies on nutritional impact of surgical techniques in oesophageal cancer are needed.

Relationship between GLIM criteria and disease-specific symptoms and its impact on 5-year survival of esophageal cancer patients

BACKGROUND & AIMS

Malnutrition is common in patients with esophageal cancer, which affects their prognosis. The global leadership initiative on malnutrition (GLIM) criteria was recently proposed as the world's first diagnostic criteria for malnutrition. However, the association between esophageal cancer patients and the GLIM criteria is unclear. The purpose of this study was to evaluate the percentage of patients diagnosed with malnutrition preoperatively using the GLIM criteria, assess the impact of disease-specific symptoms on the severity of malnutrition, and assess the prognostic relevance of GLIM defined malnutrition in patients with esophageal cancer.

METHODS

This was a retrospective single-center cohort study. Preoperative nutritional status of patients with esophageal cancer hospitalized between June 2009 and July 2011 was evaluated according to the GLIM criteria. Factors related to severe malnutrition as per the GLIM criteria were analyzed using multivariable logistic regression analysis. The association between the severity of malnutrition based on the GLIM criteria and 5-year survival was assessed using a multivariable Cox proportional hazard model.

RESULTS

Overall, 117 esophageal cancer patients were nutritionally assessed. The percentage of moderate malnutrition and severe malnutrition was 21% and 23%, respectively. Subjective dysphagia [odds ratio (OR): 7.39, 95% confidence interval (CI): 1.46-37.52] and subjective esophageal obstruction (OR: 10.49, 95% CI: 3.47-31.70) were independent risk factors for severe malnutrition. The hazard ratio (HR) for 5-year mortality tended to be higher for moderate malnutrition (HR: 2.12, 95% CI: 0.91-4.95); however, it was not significantly associated with either moderate malnutrition or severe malnutrition (HR: 1.30, 95% CI: 0.52-3.27). Cases that were censored during the follow-up period probably affected the survival results.

CONCLUSION

Subjective feelings of dysphagia and esophageal obstruction might be related to malnutrition severity in esophageal cancer patients. Malnutrition assessed by the GLIM criteria was not significantly associated with 5-year survival.

Apatinib suppresses tumor progression and enhances cisplatin sensitivity in esophageal cancer via the Akt/β-catenin pathway

Background

Esophageal cancer is the sixth leading cause of cancer-related mortality worldwide, which is partially due to limited progress of therapy. Apatinib, an inhibitor of VEGFR2, has a promising antitumor effect on malignancies. However, the underlying mechanism of its antitumor effect on esophageal cancer remains poorly understood.

Materials and methods

Eighteen pairs of frozen esophageal cancer and their para-cancer samples and 25 paraffin specimens from advanced esophageal cancer patients treated with cisplatin-based regimen were collected. The effects of apatinib on cell growth, cell apoptosis, cell cycle and invasion/migration of esophageal cancer cells were assessed. Bioinformatics, luciferase reporter, immunoprecipitation and immunofluorescence assays were conducted for mechanic investigation. Quantitative RT-PCR, western blotting and immunohistochemistry were used to measure the expression of functional genes. Xenograft tumor growth of mice was performed.

Results

We found that VEGFR2 was highly expressed in esophageal cancer and associated with poor efficacy of cisplatin-based treatment. Apatinib displayed profound actions against tumor cell growth of human esophageal cancer via promoting cell apoptosis and cell cycle arrest. Also, apatinib displayed the inhibitory effects on cell migration and invasion. Moreover, apatinib strongly suppressed the growth of esophageal cancer xenografts in mice. The effects of apatinib on esophageal cancer were partially dependent on its block of the VEGFR2/Akt/β-catenin pathway. Specifically, apatinib induced the degradation of β-catenin and decreased its transcriptional activity through Akt/GSK-3β repression. Further in vitro and in vivo studies revealed that low dose apatinib had a synergistic antitumor effect with cisplatin on esophageal cancer.

Conclusion

Our study indicates that apatinib suppresses tumor progression and enhances cisplatin sensitivity in esophageal cancer by deactivating the Akt/β-catenin pathway. These findings provide a theoretical foundation for using apatinib as an effective therapeutic drug for esophageal cancer.

Scaphoid metastasis as the first sign of occult gastroesophageal junction cancer: A case report

BACKGROUND

Metastatic tumors of the hand are very rare. They are usually late manifestations of massive advanced malignancies. However, a small portion of acrometastases are indications of occult primary cancer. Here, we report an extremely rare case in which a scaphoid bone lesion was the initial manifestation and was found to be a metastasis from gastroesophageal junction (GEJ) cancer.

CASE SUMMARY

A 57-year-old male patient presented with ongoing left wrist pain and swelling after trauma. He was initially misdiagnosed with infection of the scaphoid bone and treated with antibiotics and anti-inflammatory drugs. Further radiographic investigations showed a scaphoid pathological fracture, indicating a metastatic tumor derived from the GEJ and/or right lung malignancies. Gastroscopy failed to identify the pathology of the mass at the GEJ, which grew in an exophytic pattern. A lung puncture biopsy was not performed because the patient refused the procedure. To relieve his wrist pain and obtain a definite pathology, we resected the scaphoid lesion. Based on the clinical and pathological results, the patient was finally diagnosed with multiple metastases of advanced GEJ adenocarcinoma. He underwent chemotherapy and died 6 mo after his initial presentation.

CONCLUSION

Despite the rareness of the disease, orthopedic surgeons should consider the possibility of metastasis to the bones of the hand when patients complain of persistent and progressive pain in the hand.

A Competing Risk Analysis Study of Prognosis in Patients with Esophageal Carcinoma 2006-2015 Using Data from the Surveillance, Epidemiology, and End Results (SEER) Database

Background

Competing risk analysis determines the probability of survival and considers competing events. This retrospective study aimed to undertake a competing risk analysis of prognosis in patients with esophageal carcinoma between 2006–2015 using data from the Surveillance, Epidemiology, and End Results (SEER) database.

Material/Methods

Clinicopathological, demographic, and survival data were analyzed for patients with esophageal carcinoma registered in the SEER database between 2006–2015. The competing risk model calculated the cumulative incidence function (CIF) of events of interest and prognosis. The Cox proportional-hazards model and the cause-specific hazard function (CS) were used to generalize the hazard function for competing risks. The Fine-Gray model was used for multivariate analysis. More accurate prognostic factors were analyzed by comparing the hazard ratio (HR) values between groups.

Results

There were 14,695 patients identified with esophageal carcinoma, 9,621 died from esophageal carcinoma, and 1,251 patients died from other causes. The cumulative incidence of events of interest was significant for age at diagnosis, race, primary tumor site, grade, stage, and treatment with surgery, radiotherapy, and chemotherapy (P<0.001). Multivariate analysis showed that age at diagnosis, primary tumor site, grade, stage, and treatment with surgery, radiotherapy, and chemotherapy statuses were independent prognostic factors (P<0.05). The Fine-Gray and the CS model showed that grade, stage, and treatments with surgery, radiotherapy, and chemotherapy were significant independent prognostic factors (P<0.05).

Conclusions

A competing risk model used data from the SEER database to obtain a more accurate estimate of the CIF of esophageal carcinoma-specific mortality and prognostic factors.

Validation of the NUn score as a predictor of anastomotic leak and major complications after Esophagectomy

Predicting major anastomotic leak (AL) and major complications (Clavien-Dindo 3-5) following esophagectomy improves postoperative management of patients. The role of the NUn score in their prediction is controversial. This study aims to evaluate the predictive ability of this simple score. Data were retrospectively collected for consecutive esophagectomies over a 10-year period, and NUn scores were retrospectively calculated for each patient from informatics data. A standardized definition of major AL was used, excluding minor asymptomatic, radiologically detected leaks. The predictive accuracy of the NUn score and its constituent parts, for major AL and major complications, was assessed using area under receiver operating characteristics curves (AUROCs). Of 382 patients, 48 (13%) developed major AL and 123 (32%) developed major complications. The NUn score calculated on postoperative day 4 was significantly predictive of both outcomes, with AUROCs of 0.77 and 0.71, respectively (both P < 0.001). A NUn score cut-off of 10 had a negative predictive value of 95% for major AL. The NUn score was predictive of major complications on multivariable analysis. The NUn score was found to be a significant predictor of major AL, suggesting that this is a useful early warning score for major AL. The score may also be useful in identifying patients that are the most likely to benefit from enhanced recovery protocols.

Higher clinical suspicion is needed for prompt diagnosis of esophageal adenocarcinoma in young patients

BACKGROUND

Esophageal cancer is considered a disease of the elderly. Although the incidence of esophageal adenocarcinoma in young patients is increasing, current guidelines for endoscopic evaluation of gastroesophageal reflux disease and Barrett's esophagus include age as a cutoff. There is a paucity of data on the presentation and treatment of esophageal cancer in young patients. Most studies are limited by small sample sizes, and conflicting findings are reported regarding delayed diagnosis and survival compared with older patients.

METHODS

A retrospective cohort study was performed using the National Cancer Database between 2004 and 2015. Patients with esophageal adenocarcinoma were divided into quartiles by age (18-57, 58-65, 66-74, 75+ years) for comparison. Clinicopathologic and treatment factors were compared between groups.

RESULTS

A total of 101,596 patients were identified with esophageal cancer. The youngest patient group (18-57 years) had the highest rate of metastatic disease (34%). No difference in tumor differentiation was observed between age groups. Younger patient groups were more likely to undergo treatment despite advanced stage at diagnosis. Overall 5-year survival was better for younger patients with local disease, but the difference was less pronounced in locoregional and metastatic cases.

CONCLUSIONS

In this study, young patients were more likely to have metastatic disease at diagnosis. Advanced stage in young patients may reflect the need for more aggressive clinical evaluation in high-risk young patients.

Preoperative nutritional optimization of esophageal cancer patients

Optimization of the nutritional and metabolic state prior to major surgery leads to improved surgical outcomes and is increasingly seen as an important part of oncology disease management. For locally advanced esophageal cancer the treatment is multimodal, including neoadjuvant chemoradiotherapy or perioperative chemotherapy in combination with esophageal resection. Patients undergoing such a multimodal treatment have a higher risk for progressive decline in their nutritional status. Preoperative malnutrition and loss of skeletal muscle mass has been reported to correlate with unfavorable outcomes in patients who undergo esophageal cancer surgery. Decline in nutritional status is most likely caused by insufficient nutritional intake, reduced physical activity, systemic inflammation and the effects of anticancer therapy. To ensure an optimal nutritional status prior to surgery, it is key to assess the nutritional status in all preoperative esophageal cancer patients, preferable early in the treatment trajectory, and to apply nutritional interventions accordingly. Nutritional management of esophageal cancer can be challenging, the optimal nutritional therapy is still under debate, and warrants more nutritional scientific research. In this review, the most recent findings regarding preoperative nutrition associated with outcomes in patients with esophageal cancer will be explored.

Impact of high body mass index on surgical outcomes and long-term survival among patients undergoing esophagectomy: A meta-analysis

BACKGROUND

The impact of high body mass index (BMI, >23/25 kg/m) on surgical outcomes and prognosis in patients with esophageal carcinoma (EC) after undergoing esophagectomy remains controversial. We herein conducted a systematic review and meta-analysis to determine the relationship between high BMI and surgical outcomes and prognosis in patients undergoing esophagectomy for EC.

METHODS

The study search was conducted by retrieving publications from the PubMed, Embase, Web of Science, and CNKI (up to September 8, 2017). Nineteen studies with 13,756 patients were included in this meta-analysis.

RESULTS

We found that high BMI was closely associated with a higher incidence of wound infection (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.02-1.97, P = .04), cardiovascular complications (OR: 2.51, 95% CI, 1.65-3.81, P < .0001), and anastomotic leakage (OR: 1.50, 95% CI, 1.21-1.84, P = .0002), but a lower incidence of chylous leakage (OR: 0.59, 95% CI, 0.40-0.88, P = .01) when compared with normal BMI. The high BMI group was not associated with better or worse overall survival (OS) (hazard ratio [HR]: 0.95, 95% CI, 0.85-1.07, P = .4) and disease-free survival (HR: 0.95, 95% CI, 0.72-1.25, P = .72) than the normal BMI group. However, in the subgroup analysis, the pooled result of HRs generated from multivariate analyses suggested that high BMI could improve OS in EC patients (HR: 0.84, 95% CI, 0.76-0.93, P < .01).

CONCLUSIONS

Overweight patients with EC should not be denied surgical treatment, but intraoperative prevention and careful postoperative monitoring for several surgical complications must be stressed for this population. Besides, high BMI might be a prognostic predictor in EC patients; further studies are warranted.

Esophageal cancer in patients under 50: a SEER analysis

Background

Concomitant with rising rates of esophageal adenocarcinoma, there has been a significant increase of diagnoses among relatively younger individuals. However, most studies that focus on esophageal cancer (EC) in younger patients have had small sample sizes of patients treated at a single institute. The aim of this study was to analyze the clinical characteristics, outcomes and independent prognostic factors for EC in patients under 50-year-old using a large, multi-center dataset.

Methods

The national Surveillance, Epidemiology, and End Results (SEER) database was analyzed for EC reported from 2004 to 2013. Patients were divided into two groups, those under 50-year-old and those 50 years or older, and comparisons were made regarding demographics, histology, stage distribution, treatment, overall survival (OS), and esophageal cancer-specific survival (ECSS). Multivariate Cox proportional hazard regression analyses were also used to identify independent prognostic factors.

Results

Among the 16,544 eligible patients, 1,385 (8.37%) were under 50 and 15,159 (91.63%) were over 50. Compared with the older group, patients under 50 were characterized by a higher frequency of males, lower esophagus involvement, adenocarcinoma histology, stage III/IV disease, and receiving esophagectomy or radiation therapy. The stage-wise OS and ECSS were significantly better in the younger group (P<0.001). The multivariate analysis indicated that African-American heritage, grade III or IV, later stage, and not undergoing surgical or radiation therapy were independent negative prognostic factors of ECSS for patients under 50.

Conclusions

EC patients under 50-year-old had distinctive clinicopathological characteristics compared with patients over 50-year-old. Despite more often presenting with stage III and IV disease, survival rates were better in the younger cohort. Prognostic factors for ECSS in patients under 50 differed from those in all age patients.

Nutrition in peri-operative esophageal cancer management

Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.

Metabolic nodal response as a prognostic marker after neoadjuvant therapy for oesophageal cancer

BACKGROUND

The ability to predict recurrence and survival after neoadjuvant chemotherapy (NAC) and surgery for oesophageal cancer remains elusive. This study evaluated the role of [18 F]fluorodeoxyglucose (FDG) PET-CT in assessing tumour and nodal response as a prognostic marker.

METHODS

This was a single-centre UK cohort study. From 2006 to 2014, patients with oesophageal cancer staged with PET-CT before NAC, and restaged by CT or PET-CT before resection, were included. Pathological tumour response was evaluated using Mandard regression grades. Metabolic tumour and nodal responses (mTR and mNR respectively) were quantified using absolute and threshold reductions.

RESULTS

Among 294 included patients, mTR and mNR independently predicted prognosis before surgery. After surgery, mNR (but not mTR), pathological tumour response, resection margin status and pathological node category predicted prognosis. Patients with FDG-avid nodal disease after NAC were at high risk of recurrence/death at 1 and 2 years (43 and 71 per cent respectively; P = 0·030 and P = 0·025 versus patients without avid nodes), and had a worse prognosis than patients with non-avid nodal metastases: hazard ratio 4·19 (95 per cent c.i. 1·87 to 9·40) and 2·11 (1·12 to 3·97) respectively versus patients without nodal metastases. Considering mTR and mNR response separately improved prognostication.

CONCLUSION

mNR is a novel prognostic factor, independent of conventional N status. Primary and nodal tumours may respond discordantly and patients with FDG-avid nodes after NAC have a poor prognosis.

Management of Gastroesophageal Junction Tumors

Gastroesophageal junction tumors have been increasing in incidence over time, with most tumors presenting at a locally advanced stage. The treatment plan depends on the stage at diagnosis. PET-CT and endoscopic ultrasound are used to determine clinical stage. Depending on the location of the tumor in the esophagus and stomach, treatment can include chemotherapy with or without radiation, followed by surgery if there is no disease progression. Prognosis is related to stage at diagnosis and response to preoperative treatment. Most surgery for gastroesophageal junction tumors can be performed minimally invasively, which helps decrease postoperative length of stay and morbidity from surgery.

Decreased calorie and protein intake is a risk factor for infection and prolonged length of stay in surgical patients: A prospective cohort study

ABSTRACT Objective The aim was to assess whether postoperative calorie and protein intakes increase the risk of infection and prolonged length of stay in a tertiary care university hospital in Southern Brazil. Methods This is a prospective cohort study approved by the hospital's Research Ethics Committee. The sample consisted of adult patients undergoing elective surgery. The exclusion criteria included patients who could not undergo nutritional assessment and those with a planned hospital stay of fewer than 72 hours. Nutritional status was assessed on admission and every seven days thereafter until hospital discharge or death. Demographic and clinical data, as well as information regarding independent and outcome variables, were collected from the patient's records. Food intake assessment was conducted by researchers six times a week. Calorie and protein intakes were considered adequate if equal to or greater than 75% of the prescribed amount, and length of stay was considered prolonged when above the average for specialty and type of surgery. Data was analyzed using Poisson regression. Results Of the 519 study patients, 16.2% had adequate nutritional therapy. Most of these patients were men with ischemic heart disease and acquired immunodeficiency syndrome. After adjusting for confounders, inadequate nutritional therapy increased risk of infection by 121.0% (RR=2.21; 95%CI=1.01-4.86) and risk of prolonged length of stay by 89.0% (RR=1.89; 95%CI=1.01-3.53). Conclusion Most patients did not have adequate nutritional therapy. Those with inadequate nutritional therapy had a higher risk of infection and longer length of stay.

Attempted validation of the NUn score and inflammatory markers as predictors of esophageal anastomotic leak and major complications

The ability to predict complications following esophagectomy/extended total gastrectomy would be of great clinical value. A recent study demonstrated significant correlations between anastomotic leak (AL) and numerical values of C-reactive protein (CRP), white cell count (WCC) and albumin measured on postoperative day (POD) 4. A predictive model comprising all three (NUn score >10) was found to be highly sensitive and discriminant in predicting AL and complications. We attempted a retrospective validation in our center. Data were collected on all resections performed during a 5-year period (April 2008-2013) using prospectively maintained databases. Our biochemistry laboratory uses a maximum CRP value (156 mg/L), unlike that of the original study; otherwise all variables and outcome measures were comparable. Analysis was performed for all patients with complete blood results on POD4. Three hundred twenty-six patients underwent resection, of which 248 had POD4 bloods. There were 21 AL overall (6.44%); 16 among those with complete POD4 blood results (6.45%). There were 8 (2.45%) in-hospital deaths; 7 (2.82%) in those with POD4 results. No parameters were associated with AL or complication severity on univariate analysis. WCC was associated with AL in multivariate binary logistic regression with albumin and CRP (OR 1.23 [95% CI 1.03-1.47]; P = 0.021). When a binary variable of CRP ≥ 156 mg/L was used rather than an absolute value, no factors were significant. Mean NUn was 8.30 for AL, compared with 8.40 for non-AL (P = 0.710 independent t-test). NUn > 10 predicted 0 of 16 leaks (sensitivity 0.00%, specificity 94.4%, receiver operator curve [ROC] area under the curve [AUC] 0.485; P = 0.843). NUn > 7.65 was 93% sensitive and 21.6% specific. ROC for WCC alone was comparable with NUn (AUC 0.641 [0.504-0.779]; P = 0.059; WCC > 6.89 93.8% sensitive, 20.7% specific; WCC > 15 6.3% sensitive and 97% specific). There were no associations between any parameters and other complications. In a comparable cohort with the original study, we demonstrated a similar multivariate association between WCC alone on POD4 and subsequent demonstration of AL, but not albumin or CRP (measured up to 156 mg/L). The NUn score overall (calculated with this caveat) and a threshold of 10 was not found to have clinical utility in predicting AL or complications.

Longitudinal and circumferential resection margin in adenocarcinoma of distal esophagus and cardia

Multiple factors are implicated in the long-term survival of patients who have undergone esophagectomy, among these the involvement of longitudinal and circumferential resection margins are well known important prognostic factors. A few studies have assessed the impact of the operative approach on the status of the resection margins, and the data are not well reported, often unclear and, more importantly, there is no scientific evidence or published guideline on what the optimal proximal, distal or circumferential resection margin clearance should be. Owing to the lack of clarity on these points, we undertook a systematic literature review of the impact of longitudinal and circumferential resection margins in patients with operable esophageal cancer, the prognostic significance of margin involvement and the role of neoadjuvant therapy.

Individual risk modelling for esophagectomy: a systematic review

INTRODUCTION

A number of models have been applied to predict outcomes from esophagectomy. This systematic review aimed to compare their clinical credibility, methodological quality and performance.

METHODS

A systematic review of the PubMed, EMBASE and Cochrane databases was performed in October 2012. Model and study quality were appraised using the framework of Minne et al.

RESULTS

Twenty studies were included in total; these were heterogeneous, retrospective and conducted over a number of years; all models were generated via logistic regression. Overall mortality was high, and consequently not representative of current practice. Clinical credibility and methodological quality were variable, with frequent failure to perform internal validation and variable presentation of calibration and discrimination metrics. P-POSSUM demonstrated the best calibration and discrimination for predicting mortality. Other than the Southampton score (which has yet to be externally validated) and the Amsterdam score, no studies had utility in predicting complications.

CONCLUSION

Whilst a number of models have been developed, adapted or trialled, due to numerous limitations, larger and more contemporary studies are required to develop and validate models further. The role of alternative techniques such as decision tree analysis and artificial neural networks is not known.

The effect of formalizing enhanced recovery after esophagectomy with a protocol

Enhanced recovery after surgery (ERAS) pathways aim to accelerate functional return and discharge from hospital. They have proven effective in many forms of surgery, most notably colorectal. However, experience in esophagectomy has been limited. A recent study reported significant reductions in pulmonary complications, mortality, and length of stay following the introduction of an ERAS protocol alone, without the introduction of any clinical changes. We instituted a similar change 16 months ago, introducing a protocol to provide a formal framework, for our existing postoperative care. This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change. Data were collected from prospectively maintained secure web-based multidisciplinary databases. Complication severity was classified using the Clavien-Dindo scale. Operative mortality was defined as death within 30 days of surgery, or at any point during the same hospital admission. Lower respiratory tract infection was defined as clinical evidence of infection, with or without radiological signs. Respiratory complications included lower respiratory tract infection, pleural effusion (irrespective of drainage), pulmonary collapse, and pneumothorax. Statistical analysis was performed using SPSS v21. One hundred thirty-two patients underwent esophagectomy (55 protocol group; 77 before). All were performed open. There were no differences between the two groups in terms of age, gender, operation, use of neoadjuvant therapy, cell type, stage, tumor site, or American Society of Anesthesiologists grade. Median length of stay was 14.0 days (protocol) compared with 12.0 before (interquartile range 9-19 and 9.5-15.5, respectively; P = 0.073, Mann-Whitney U-test). Readmission within 30 days of discharge occurred in five (9.26%) and six (8.19%; P = 1.000, Fisher's exact test). There were four in-hospital deaths (3.03%): one (1.82%) and three (3.90%), respectively (P = 0.641). There were no differences in the severity of complications (P = non-significant; Pearson's chi-squared). There were no differences in the type of complications occurring in either group. The protocol was completed successfully by 26 (47.3%). No baseline factors were predictive of this. In contrast to previous studies, we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol. Consequently, improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care. Consequently, we would recommend that centers introducing new (or reviewing existing) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such standardized pathways.

Prognostic factors and causes of death in patients cured of esophageal cancer

BACKGROUND

The number of patients cured of esophageal cancer after esophagectomy is gradually increasing owing to advances in surgical techniques, perioperative management, and adjuvant therapies. This study assessed the clinical course and sought to identify the prognostic factors of these patients.

METHODS

A series of 220 consecutive patients who underwent esophagectomy and survived for more than 5 years with no relapse were enrolled. Survival analysis was performed using 25 variables including patient characteristics and operative and perioperative factors. Potential prognostic factors were identified by univariate and multivariate analyses, and the development of other primary cancers and the causes of death were retrospectively reviewed.

RESULTS

The overall 10-, 15-, and 20-year survival rates were 71.6, 50.1, and 32.2 %, respectively, with a median survival time of 180 months (range, 61-315 months). The negative independent prognostic factors identified were age at surgery [hazard ratio (HR), 1.05; P < .01], being male (HR, 2.62; P = .02), pulmonary comorbidities (HR, 2.03; P = .02), synchronous presence of other cancers (HR, 2.35; P < .01), colonic/jejunal interposition (HR, 1.76; P = .03), perioperative blood transfusion (HR, 1.92; P = .02), development of pulmonary complications (HR, 1.71; P = .02), and adjuvant radiotherapy (HR, 2.13; P = .01). Pulmonary diseases and other primary cancers were found to be the most common causes of death.

CONCLUSIONS

Careful follow-up including the surveillance of other primary cancers is required for long-term survivors of esophageal cancer after esophagectomy.

Treatment and outcome of young patients with esophageal cancer in the Netherlands

BACKGROUND

Esophageal cancer is increasingly recognized in younger patients. We compared clinicopathological characteristics, treatment, and survival of patients aged ≤50 years with patients aged >50 years diagnosed with esophageal cancer in the Netherlands.

METHODS

From the nationwide Netherlands Cancer Registry we identified all patients diagnosed with esophageal cancer between January 2000 and January 2011. Proportions were compared using the χ(2) test for categorical variables. Overall and relative survival was calculated.

RESULTS

Eleven percent of the patients (n = 1,466) were aged ≤50 years and adenocarcinoma was the most common tumor type (73.6%). Grade of tumor differentiation was comparable between both age groups (P = 0.460) as well as T-stage (P = 0.058). Younger patients presented more often with positive lymph nodes (70.1% vs. 66.4%, P = 0.010) and distant metastasis (50.5% vs. 44.7%, P < 0.001) but had surgery more often as compared to older patients: 40.6% versus 37.9%, P = 0.047. There was no significant difference in the 5-year relative survival between both age groups: 18.1% versus 17.2%, P > 0.05. A subgroup analysis among patients diagnosed with adenocarcinoma revealed similar results.

CONCLUSIONS

Young patients with esophageal cancer present with more advanced disease stage and received more often treatment. However, they show comparable relative survival rates with their older counterparts.

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.

Pretreatment Patient Comorbidity and Tobacco Use Increase Cost and Risk of Postoperative Complications After Esophagectomy at a High-Volume Cancer Center

Although direct cost comparisons between institutions may not yet be possible, the model and methods the authors used to assess variance in cost of esophagectomy could be adopted for use in different clinical settings.