Patient-reported outcomes after oesophagectomy in the multicentre LASER study

Post-Esophagectomy Dumping Syndrome: Assessing Quality of Life of Long-Term Survivors

Background/Objectives: Survival rates for esophageal cancer patients have markedly improved. Inevitably, attention has been drawn to functional and quality-of-life problems. The aim of the current study was to investigate the prevalence of dumping syndrome in patients following esophageal resection and its correlation with postoperative quality of life. Methods: This cross-sectional study involved disease-free patients who underwent a potentially curative resection for esophageal or gastroesophageal junction carcinoma between January 2019 and January 2024 in a single academic institution. Patients were asked to fill in two questionnaires: the Dumping Syndrome Rating Scale (DSRS) and the QLQ-OG25. A Composite Dumping Syndrome Index (CDSI) was calculated by adding the summary severity and frequency scores for each patient. Results: During the study period, 42 patients underwent esophagectomy for malignant esophageal or junctional tumors. In total, 14 eligible patients responded to the questionnaires at a mean time of 19.7 (±20.8) months following their operation. Three patients (21%) reported having at least quite severe problems related to at least two dumping symptoms. Six patients (43%) reported that they avoid certain foods in order to alleviate related problems. A high CDSI score was associated with significantly increased OG25 scores for dysphagia, eating restriction, odynophagia, pain and discomfort, and reflux (p < 0.05). Conclusions: Early dumping syndrome can occur in a significant proportion of patients following esophagectomy and may adversely affect quality of life.

Evaluating the Impact of Minimally Invasive Surgery on Long-Term Quality of Life in Foregut Cancer Patients

INTRODUCTION

Compared to open surgery (OS), minimally invasive surgery (MIS) for foregut cancer improves perioperative outcomes. However, the impact of MIS on long-term quality of life (QOL) is unknown. We compare the long-term QOL of patients who underwent MIS and OS for foregut cancer.

METHODS

Surgically managed esophageal and gastric cancer patients were surveyed globally via online support groups. Physical (P-QOL) and mental (M-QOL) well-being were determined using the Short Form-12 questionnaire and compared based on the surgical approach (MIS vs OS). We defined "long-term" as greater than 3 months from surgery.

RESULTS

Out of 100 respondents with esophageal and gastric cancer, 64 survivors underwent surgical management greater than 3 months before the survey. They were 56.6 ± 9.9 years, 46.0% female, and 95.2% White, with a median survival of 33.0 (14.0-63.0) months. The most common diagnosis was esophageal adenocarcinoma (69.8%). Surgical procedures included esophagectomy (56.5%), esophagogastrectomy (29.0%), and gastrectomy (14.5%), of which 45.2% were OS and 48.4% were MIS. The cohort overall exhibited lower P-QOL (40.7 ± 10.4) and M-QOL (44.6 ± 15.2) compared to the general population (50.0 ± 10.0; p < 0.050). There was no difference in age, sex, race, education, income, diagnosis, and adjuvant therapy between OS and MIS cohorts (all p > 0.050). Long-term P-QOL (38.5 ± 11.6 OS vs. 42.8 ± 9.5 MIS, p = 0.123) and M-QOL (44.7 ± 15.3 OS vs. 44.9 ± 14.9 MIS, p = 0.901) was similar between patients who underwent OS and MIS for foregut cancer.

CONCLUSION

MIS is not associated with higher long-term QOL in patients who have undergone surgery for foregut malignancy.

Prevalence and Risk Factors for Malignant Nodal Involvement in Early Esophago-Gastric Adenocarcinoma: Results From the Multicenter Retrospective Congress Study (endosCopic resectiON, esophaGectomy or Gastrectomy for Early Esophagogastric Cancers)

OBJECTIVE

The aim of this study was to quantify lymph node metastasis (LNM) risk and outcomes following treatment of early esophago-gastric (EG) adenocarcinoma.

BACKGROUND

The standard of care for early T1N0 EG cancer is endoscopic resection (ER). Radical surgical resection is recommended for patients perceived to be at risk of LNM. Current models to select organ-preserving versus surgical treatment are inconsistent.

METHODS

CONGRESS is a UK-based multicenter retrospective cohort study. Patients diagnosed with clinical or pathological T1N0 EG adenocarcinoma from 2015 to 2022 were included. Outcomes and rates of LNM were assessed. Cox regression was performed to assess the impact of prognostic and treatment factors on overall survival.

RESULTS

A total of 1601 patients from 26 centers were included, with median follow-up 32 months (IQR 14-53). 1285/1612 (80.3%) underwent ER, 497/1601 (31.0%) underwent surgery. Overall rate of LNM was 13.5%. On ER staging, tumour depth (T1bsm2-3 17.6% vs T1a 7.1%), lymphovascular invasion (17.2% vs 12.6%), or signet cells (28.6% vs 13.0%) were associated with LNM. In multivariable regression analysis, these were not significantly associated with LNM rates or survival. Adjusting for demographic and tumour variables, surgery after ER was associated with significant survival benefit, HR 0.33 (0.15-0.77), P =0.010.

CONCLUSIONS

This large multicenter data set suggests that early EG adenocarcinoma is associated with significant risk of LNM. These data are representative of current real clinical practice with ER-based staging, and suggests previously held beliefs regarding reliability of predictive factors for LNM may need to be reconsidered. Further research to identify patients who may benefit from organ-preserving versus surgical treatment is urgently required.

A multi-center study of symptoms in patients with esophageal cancer postoperatively: A networking analysis

PURPOSE

This study aimed to explore symptom clusters and the inter-relationship of symptoms in esophageal cancer (EC) patients during the first week after surgery.

METHODS

A cross-sectional survey across multiple centers was carried out using the EORTCQLQ-OES18. Patients with esophageal cancer within a week post-surgery were recruited from the "Be Resilient to Cancer" project in Guangdong, Hunan, and Sichuan provinces between January and September 2024. Exploratory factor analysis with a priori algorithm was used to identify symptom clusters and network analysis was employed to recognize the relationship among core and bridge symptoms.

RESULTS

The sample consisted of 501 patients with esophageal cancer, who were predominantly male (83%), married (93%) and 57% were ≥60 years. Three symptom clusters were identified: "reflux-pain", "eating", and "dysphagia-dry mouth". Acid or bile coming up (support = 40.1%, confidence = 1, lift = 2.53), eating difficulties (support = 40.1%, confidence = 0.990, lift = 2.408) and dry mouth (support = 42.9%, confidence = 0.808, lift = 1.298) were marked as sentinel symptoms for these clusters, respectively. Acid indigestion or heartburn was identified as the core symptom (EI = 1.142 without covariates and EI = 1.153 with covariates), and dry mouth served as the bridge symptoms (EI = 0.63 and EI = 0.656).

CONCLUSIONS

Addressing acid or bile coming up, eating difficulties, dry mouth are imperative to help relief symptom burden at the cluster level. Furthermore, targeting acid indigestion and heartburn are crucial to break the chains among different symptom clusters.

Long-term quality of life after hybrid robot-assisted and open Ivor Lewis esophagectomy for esophageal cancer in a single center: a comparative analysis

PURPOSE

Due to improved survival of esophageal cancer patients, long-term quality of life (QoL) is increasingly gaining importance. The aim of this study is to compare QoL outcomes between open Ivor Lewis esophagectomy (Open-E) and a hybrid approach including laparotomy and a robot-assisted thoracic phase (hRob-E). Additionally, a standard group of healthy individuals serves as reference.

METHODS

With a median follow-up of 36 months after hRob-E (n = 28) and 40 months after Open-E (n = 43), patients' QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30 (QLQ-C30) and the EORTC Esophagus specific QoL questionnaire 18 (QLQ-OES18).

RESULTS

Patients showed similar clinical-pathological characteristics, but hRob-E patients had significantly higher ASA scores at surgery (p < 0.001). Patients and healthy controls reported similar global health status and emotional and cognitive functions. However, physical functioning of Open-E patients was significantly reduced compared to healthy controls (p = 0.019). Operated patients reported reduced role and social functioning, fatigue, nausea and vomiting, dyspnea, and diarrhea. A trend towards a better pain score after hRob-E compared to Open-E emerged (p = 0.063). Regarding QLQ-OES18, hRob-E- and Open-E-treated patients similarly reported eating problems, reflux, and troubles swallowing saliva.

CONCLUSIONS

The global health status is not impaired after esophagectomy. Despite higher ASA scores, QoL of hRob-E patients is similar to that of patients operated with Open-E. Moreover, patients after hRob-E appear to have a better score regarding physical functioning and a better pain profile than patients after Open-E, indicating a benefit of minimally invasive surgery.

Sex-related differences in oncologic outcomes, operative complications and health-related quality of life after curative-intent oesophageal cancer treatment: multicentre retrospective analysis

BACKGROUND

Oesophageal cancer, in particular adenocarcinoma, has a strong male predominance. However, the impact of patient sex on operative and oncologic outcomes and recovery of health-related quality of life is poorly documented, and was the focus of this large multicentre cohort study.

METHODS

All consecutive patients who underwent oncological oesophagectomy from 2009 to 2015 in the 20 European iNvestigation of SUrveillance after Resection for Esophageal cancer study group centres were assessed. Clinicopathologic variables, therapeutic approach, postoperative complications, survival and health-related quality of life data were compared between male and female patients. Multivariable analyses adjusted for age, sex, tumour histology, treatment protocol and major complications. Specific subgroup analyses comparing adenocarcinoma versus squamous cell cancer for all key outcomes were performed.

RESULTS

Overall, 3974 patients were analysed, 3083 (77.6%) male and 891 (22.4%) female; adenocarcinoma was predominant in both groups, while squamous cell cancer was observed more commonly in female patients (39.8% versus 15.1%, P < 0.001). Multivariable analysis demonstrated improved outcomes in female patients for overall survival (HRmales 1.24, 95% c.i. 1.07 to 1.44) and disease-free survival (HRmales 1.22, 95% c.i. 1.05 to 1.43), which was caused by the adenocarcinoma subgroup, whereas this difference was not confirmed in squamous cell cancer. Male patients presented higher health-related quality of life functional scores but also a higher risk of financial problems, while female patients had lower overall summary scores and more persistent gastrointestinal symptoms.

CONCLUSION

This study reveals uniquely that female sex is associated with more favourable long-term survival after curative treatment for oesophageal cancer, especially adenocarcinoma, although long-term overall and gastrointestinal health-related quality of life are poorer in women.

Early-Onset Cancer in the Gastrointestinal Tract Is on the Rise-Evidence and Implications

Epidemiologic data indicate a significant increase in the incidence of colorectal cancer in younger populations in the past three decades. Moreover, recent evidence also demonstrates a similar trend in gastric, pancreatic, and biliary tract cancers. A majority of these early-onset cases are sporadic and lack hereditary or familial background, implying a potential key role for behavioral, lifestyle, nutritional, microbial, and environmental factors. This review explores the current data on early-onset gastrointestinal cancer, exploring the etiology, unique treatment considerations for this population, future challenges, as well as implications for research and practice.

SIGNIFICANCE

The worrisome trend of an increasing incidence of early-onset gastrointestinal cancers appears to be correlated with nonhereditary etiologies in which behavioral, lifestyle, nutritional, microbial, and environmental factors, as well as host mechanisms, may play a key role. Further epidemiologic and pathogenetic research is urgently needed to better understand the underlying mechanisms and to develop preventive strategies and tailored early detection. Young patients with gastrointestinal cancer face unique challenges and unmet needs. These must be addressed in the future management of the disease to minimize treatment-related somatic morbidity and prevent psychosocial sequelae.

Prevalence, nature and trajectory of dysphagia postoesophageal cancer surgery: a prospective longitudinal study protocol

INTRODUCTION

Dysphagia is a common problem following oesophagectomy, and is associated with aspiration pneumonia, malnutrition, weight loss, prolonged enteral feeding tube dependence, in addition to an extended in-hospital stay and compromised quality of life (QOL). To date, the prevalence, nature and trajectory of post-oesophagectomy dysphagia has not been systematically studied in a prospective longitudinal design. The study aims (1) to evaluate the prevalence, nature and trajectory of dysphagia for participants undergoing an oesophagectomy as part of curative treatment, (2) to determine the risk factors for, and post-operative complications of dysphagia in this population and (3) to examine the impact of oropharyngeal dysphagia on health-related QOL across time points.

METHODS AND ANALYSIS

A videofluoroscopy will be completed and analysed on both post-operative day (POD) 4 or 5 and at 6-months post-surgery. Other swallow evaluations will be completed preoperatively, POD 4 or 5, 1-month and 6-month time points will include a swallowing screening test, tongue pressure measurement, cough reflex testing and an oral hygiene evaluation. Nutritional measurements will include the Functional Oral Intake Scale to measure feeding tube reliance, Malnutrition Screening Tool and the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs and Falls questionnaire. The Reflux Symptom Index will be administered to investigate aerodigestive symptoms commonly experienced by adults post-oesophagectomy. Swallowing-related QOL outcome measures will be determined using the European Organisation for Research and Treatment of Cancer QLQ-18, MD Anderson Dysphagia Inventory and the Swallowing Quality of Life Questionnaire.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Tallaght University Hospital/St. James' Hospital Research Ethics Committee (JREC), Dublin, Ireland (Ref. No. 2021-Jul-310). The study results will be published in peer-reviewed journals and presented at national and international scientific conferences.

Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma

Background

Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma.

Summary

Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma.

Key Messages

In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.

Prediction of severe reflux after oesophageal cancer surgery

INTRODUCTION

A common and burdensome consequence of oesophagectomy for cancer is reflux. This study aimed to develop a risk prediction model for postoperative reflux using variables available at the time of surgery enabling tailored preventive symptom management.

METHODS

Data were obtained from a nationwide, population-based cohort of 921 adults who underwent oesophagectomy for cancer between 2013 and 2019. Among 569 eligible patients, 383 (67%) participated in the study. Patient and clinical characteristics were retrieved from national health registries and medical records. Postoperative reflux was self-reported 1 year after surgery in the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire module for gastroesophageal symptoms. Multivariable regression models provided odds ratios (OR) with 95% confidence intervals (CI). The performance of the model was evaluated using the area under the receiver-operating characteristic curve.

RESULTS

Female sex (OR 2.24, 95% CI: 1.00-5.00), preoperative reflux (OR 2.99, 95% CI: 1.61-5.52), and preoperative body mass index ≥30 (OR 2.45, 95% CI: 1.32-4.54) increased the risk of postoperative reflux. A model based on age, sex, preoperative reflux, body mass index, chronic obstructive pulmonary disease, and ventricle substitute predicted 72% of the severe cases.

CONCLUSION

Female sex, preoperative reflux, and preoperative body mass index increased the risk of postoperative reflux. A combination of readily available patient and preoperative clinical variables showed fairly good accuracy in predicting postoperative reflux after oesophagectomy. The clinical risk prediction model may be helpful for early symptom management but needs to be externally validated before wider use.