Postoperative complications after transthoracic esophagectomy for cancer of the esophagus and gastroesophageal junction are correlated with early cancer recurrence: role of systematic grading of complications using the modified Clavien classification. Ann Surg. 2009;250:798-807. [PMID: 19809297 DOI: 10.1097/sla.0b013e3181bdd5a8]

Severe postoperative complications after minimally invasive esophagectomy reduce the long-term prognosis of well-immunonutrition patients with locally advanced esophageal squamous cell carcinoma

BACKGROUND

While severe postoperative complications (SPCs) impact cancer prognosis, their effect on locally advanced esophageal squamous cell carcinoma (ESCC) patients with varying immunonutritional statuses after minimally invasive esophagectomy (MIE) is unclear.

METHODS

This retrospective study analyzed 442 patients with locally advanced ESCC who underwent MIE, investigating the relationship between SPCs and survival based on preoperative immunonutritional status, determined by the prognostic nutritional index (PNI). Nomograms were developed for patients with preserved immunonutritional status using Cox regression, and their performance was assessed.

RESULTS

Of the patients, 102 (23.1%) experienced SPCs after MIE. Five-year overall survival (OS) and disease-free survival (DFS) were significantly different between SPCs and non-SPCs groups (p < 0.001). In the preserved immunonutritional group, SPCs significantly reduced 5-year OS (p = 0.008) and DFS (p = 0.011), but not in the poor immunonutritional group (OS p = 0.152, DFS p = 0.098). Multivariate Cox regression identified SPCs as an independent risk factor for OS (HR = 1.653, p = 0.013) and DFS (HR = 1.476, p = 0.039). A nomogram for predicting OS and DFS in preserved immunonutritional patients demonstrated excellent performance.

CONCLUSIONS

SPCs significantly affect prognosis in ESCC patients with preserved immunonutritional status after MIE. Nomograms based on SPCs can predict OS and DFS in these patients.

Predictive model for postoperative pneumonia in patients with esophageal cancer after esophagectomy

Background

Pneumonia is one of the most common complications after esophagectomy and a risk factor affecting postoperative survival of esophageal cancer. The aim of this study was to identify risk factors and construct a predictive model for postoperative pneumonia (POP) in esophageal cancer.

Methods

This retrospective cohort study included esophageal cancer patients who underwent therapeutic esophagectomy from June 2019 to December 2023. Least absolute shrinkage and selection operator (LASSO) regression was used to screen predictive factors for POP, and a nomogram was constructed based on the selected predictive factors after screening. The performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

A total of 667 esophageal cancer patients who underwent esophagectomy were included, of whom 61 (9.1%) developed postoperative pneumonia. After LASSO regression analysis, factors independently associated with POP included mechanical ventilation for more than 2 days (P=0.000) and blood transfusion (P=0.003). A nomogram was constructed based on these independent risk factors. The AUC of the predictive model for POP was 0.839 (95%CI: 0.768-0.911). The internal verification result showed a good discriminative power and the DCA results demonstrated a good predictive value.

Conclusion

The predictive model constructed in this study can predict the risk of POP in patients with esophageal cancer, and may promote early intervention for high-risk patients by clinicians to reduce the incidence of POP.

Prognostic significance of perioperative circulating CD56bright NK cell and recovery of NK cell activity in patients with colorectal cancer undergoing radical surgery

INTRODUCTION

Natural killer (NK) cell activity (NKA) is downregulated in patients with colorectal cancer (CRC), and its dysfunction is possibly associated with increased risk of recurrence. However, its role in prognosis of CRC remains unclear. Prior research has shown that surgical stress can suppress NKA. This study explores the relationship between NK cell/NKA and clinicopathological factors during the perioperative period in patients with CRC.

METHODS

We prospectively enrolled 45 patients with CRC. Venous blood samples were collected preoperatively and on postoperative day 3 (POD3) and 30 (POD30). NKA was assessed by measuring the plasma levels of NK cell-secreted IFN-γ.

RESULTS

NKA was significantly reduced on POD3 compared with baseline levels before surgery but showed significant recovery by POD30. NKA on POD30 was considerably higher in patients with advanced disease stages or one or more high-risk preoperative factors. Additionally, a higher NKA recovery in patients with advanced stage exhibited improved recurrence-free survival (RFS) and progression-free survival (PFS) (hazards ratio (HR): 0.2442). Furthermore, an increased percentage of CD56bright NK cells and a higher CD56bright/CD56dim NK cell ratio postoperatively on POD30 were associated with better RFS/PFS (HR: 0.2732, P = 0.0433 and HR: 0.2193, P = 0.024, respectively).

CONCLUSIONS

Our findings indicate that a notable postoperative increase in CD56bright NK cells on POD30, both in percentage and ratio, correlates with a more favorable prognosis in CRC patients. Additionally, higher recovery rates of NKA in patients with advanced stages may offer potential applications in risk stratification and the development of treatment strategies for CRC.

The Effect of Postoperative Sepsis on 1-Year Mortality and Cancer Recurrence Following Transhiatal Esophagectomy for Esophageal-Gastric Junction Adenocarcinomas: A Retrospective Observational Study

INTRODUCTION

Transhiatal esophagectomy (THE) is used for specific gastroesophageal junction adenocarcinomas. THE is a high-risk surgical procedure. We aimed to assess the impact of postoperative sepsis (sepsis or septic shock) on the 1-year mortality after THE and to determine the risk factors associated with these outcomes. Secondly, we aimed to assess the impact of postoperative sepsis and other risk factors on 1-year cancer recurrence.

METHOD

A retrospective, observational study was undertaken at the Paoli-Calmettes Institute, Marseille, from January 2012 to March 2022.

RESULTS

Of 118 patients, 24.6% (n = 29) presented with postoperative sepsis. Their 1-year mortality was 11% (n = 13), and their 1-year cancer recurrence was 23.7% (n = 28). In the multivariate analysis, independent factors for 1-year mortality were the following: postoperative sepsis (OR: 7.22 (1.11-47); p = 0.038), number of lymph nodes removed (OR: 0. 78 (0.64-0.95); p = 0.011), recurrence at one year (OR: 9.22 (1.66-51.1); p = 0.011), mediastinitis (OR: 17.7 (1.43-220); p = 0.025) and intraoperative driving pressure (OR: 1.77 (1.17-2.68); p = 0.015). For postoperative sepsis, independent factors were low-dose vasopressors (OR: 0.26; 95% CI: 0.07-0.95; p = 0.049), a cervical abscess (OR: 5.33; 95% CI: 1.5-18.9; p = 0.01), bacterial pneumonia (OR: 11.1; 95% CI: 2.99-41.0; p < 0.001) and a high SOFA score on day 1 (OR: 2.65; 95% CI: 1.36-5.19; p = 0.04). For 1-year cancer recurrence, independent factors were the number of lymph nodes removed (sHR: 0.87; 95% CI: 0.79-0.96; p = 0.005), pTNM stages of III or IV (sHR: 8.29; 95% CI: 2.71-25.32; p < 0.001) and postoperative sepsis (sHR: 6.54; 95% CI: 1.70-25.13; p = 0.005).

CONCLUSIONS

Our study indicates that after THE, postoperative sepsis influences survival and cancer recurrence. We identified the associated risk factors, suggesting an early diagnosis might decrease mortality and recurrence.

The totally mechanical Collard technique for cervical esophagogastric anastomosis reduces anastomotic stricture compared with triangular anastomosis in minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route: a propensity score-matched study

BACKGROUND

Cervical esophagogastric anastomosis is conventionally performed using the McKeown esophagectomy. However, an optimal anastomotic technique has not yet been established. This study aimed to compare the clinical outcomes of triangular anastomosis (TA) and totally mechanical Collard anastomosis (TMCA) for cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.

METHODS

In this matched- cohort study, 117 patients who underwent minimally invasive esophagectomy between 2019 and 2024 were divided into TA and TMCA groups. The TA technique was performed between September 2019 and December 2021, and the TMCA technique was performed between January 2022 and January 2024. We then compared the surgical outcomes and postoperative complications (pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, and stricture) between the two groups.

RESULTS

Propensity score matching revealed that 40 patients were included in both the TA and TMCA groups. The rates of pneumonia, recurrent laryngeal nerve palsy, and anastomotic leakage were not significantly different between the two groups. However, the rate of anastomotic stricture was lower in the TMCA than in the TA group (2.5% vs. 27.5%, respectively, P = 0.003).

CONCLUSIONS

Compared with the TA technique, the TMCA technique reduced the rate of anastomotic stricture when performing cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.

Prognostic factors for patients with pathologic T1-T2N+ esophageal squamous cell carcinoma: A retrospective study with external validation

BACKGROUND

Lymph node metastasis is significantly associated with a worse prognosis in patients with localized early-stage esophageal squamous cell carcinoma. This study aimed to explore the prognostic factors and develop a nomogram for predicting survival in patients with pathologic T1-2N+ esophageal squamous cell carcinoma.

METHODS

Between 2014 and 2022, patients with pT1-2N+ esophageal squamous cell carcinoma who underwent esophagectomy with lymphadenectomy at 2 institutes were reviewed and assigned to training and external validation cohorts. Independent prognostic factors were identified via univariate and multivariate Cox regression analyses. The nomogram model was developed and evaluated by the area under the receiver operating characteristic curve and calibration curve.

RESULTS

In total, 268 patients with a median age of 65 years (range, 40-82) were included and assigned to training (n = 190) and external validation (n = 78) cohorts. The Cox proportional hazards model demonstrated that body mass index (P = .031), surgical approach (P < .001), T stage (P = .015), and Clavien-Dindo classification (P < .001) were independent prognostic factors in the training cohort. The nomogram showed good discrimination, with an area under the receiver operating characteristic curve for 1-year, 3-year, and 5-year of 0.810, 0.789, and 0.809 in the training cohort and 0.782, 0.679, and 0.698 in the validation cohort. The calibration curve showed that the predicted survival probability was in good agreement with the actual survival probability.

CONCLUSION

Lower body mass index, left surgical approach, T2 stage, and Clavien-Dindo classification grade III to V were related to worse prognosis in patients with pT1-T2N+ esophageal squamous cell carcinoma. The developed nomogram may predict individual survival accurately.

The Risk of Infection-Caused Mortality in Gastric Adenocarcinoma: A Population-Based Study

Background

Gastric adenocarcinoma (GAC) is a deadly tumor. Postoperative complications, including infections, worsen its prognosis and may affect overall survival. Little is known about perioperative complications as well as modifiable and non-modifiable risk factors. Early detection and treatment of these risk factors may affect overall survival and mortality.

Methods

We extracted GAC patient's data from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed using Pearson's Chi-square, Cox regression, Kaplan-Meier, and binary regression methods in SPSS.

Results

At the time of analysis, 59,580 GAC patients were identified, of which 854 died of infection. Overall, mean survival in months was better for younger patients, age < 50 years vs. ≥ 50 years (60.45 vs. 56.75), and in females vs. males (65.23 vs. 53.24). The multivariate analysis showed that the risk of infectious mortality was higher in patients with age ≥ 50 years (hazard ratio (HR): 3.137; 95% confidence interval (CI): 2.178 - 4.517), not treated with chemotherapy (HR: 1.669; 95% CI: 1.356 - 2.056), or surgery (HR: 1.412; 95% CI:1.132 - 1.761) and unstaged patients (HR: 1.699; 95% CI: 1.278 - 2.258). In contrast, the mortality risk was lower in females (HR: 0.658; 95% CI: 0.561 - 0.773) and married patients (HR: 0.627; 95% CI: 0.506 - 0.778). The probability of infection was higher in older patients (odds ratio (OR) of 2.094 in ≥ 50 years), other races in comparison to Whites and Blacks (OR: 1.226), lesser curvature, not other specified (NOS) as a primary site (OR: 1.325), and patients not receiving chemotherapy (OR: 1.258).

Conclusion

Older, unmarried males with GAC who are not treated with chemotherapy or surgery are at a higher risk for infection-caused mortality and should be given special attention while receiving treatment.

Textbook oncological outcomes and prognosis after curative gastrectomy in advanced gastric cancer: A multicenter study

BACKGROUND

The impact of achieving textbook oncological outcome (TOO) as a multimodal therapy quality indicator on the prognosis of advanced gastric cancer (AGC) remains inadequately assessed.

METHODS

Patients with AGC who underwent curative gastrectomy between January 2010 and December 2017 at two East Asian medical centers were included. TOO was defined as achieving the textbook outcome (TO) and receiving neoadjuvant and/or adjuvant chemotherapy (NCT or ACT). Cox and logistic regression models were used to identify prognostic and non-TOO-associated risk factors.

RESULTS

Among 3626 patients, 57.6% achieved TOO (TOO group), exhibiting significantly better 5-year overall survival (OS) and disease-free survival (DFS) than the non-TOO group (both p < 0.05). Multivariate Cox regression identified TOO as an independent prognostic factor for 5-year OS (HR, 0.67; 95% CI, 0.61-0.74; p < 0.001) and DFS (HR, 0.73; 95% CI, 0.66-0.81; p < 0.001). Multivariate logistic regression showed that open gastrectomy, lack of health insurance, age ≥65 years, ASA score ≥ Ⅲ, and tumor size ≥50 mm are independent risk factors for non-achievement of TOO (all p < 0.05). On a sensitivity analysis of TOO's prognostic value using varying definitions of chemotherapy parameters, a stricter definition of chemotherapy resulted in a decrease in the TOO achievement rate from 57.6 to 22.3%. However, the associated reductions in the risk of death and recurrence fluctuated within the ranges of 33-39% and 28-37%, respectively.

CONCLUSIONS

TOO is a reliable and stable metric for favorable prognosis in AGC. Optimizing the surgical approach and improving health insurance status may enhance TOO achievement.

Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial

Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.

Development and Validation of a Prognostic Model for Postoperative Anastomotic Recurrence in Siewert II or III Adenocarcinomas Without Neoadjuvant Therapy in an East Asian Population

PURPOSE

Anastomotic recurrence leads to poor prognosis in patients with Siewert II or III adenocarcinoma who undergo radical gastrectomy and do not receive neoadjuvant therapy. We aimed to establish a prognostic model to evaluate the risk of postoperative anastomotic recurrence in patients with Siewert II or III adenocarcinoma who did not receive neoadjuvant therapy.

METHODS

We included 366 patients with Siewert II or III adenocarcinoma who were treated with radical gastrectomy without neoadjuvant therapy at Fujian Provincial Hospital (FPH) between 2012 and 2018 as the development cohort. Cox regression was used to verify prognostic factors for anastomotic recurrence, and a nomogram was established. The nomogram was externally validated using a combined cohort of two external centers. Patients were classified into high- or low-risk groups according to the diagnostic threshold and nomogram scores, and recurrence-related survival analysis was analyzed.

RESULTS

The average age was 64.6 years, and 285 patients were male. All surgeries were successfully performed (185 open vs 181 laparoscopic). The 3-year anastomotic recurrence rate was significantly lower in the low-risk group (3.5% vs 18.8%, P < 0.001). The predictive performance was verified in the external validation cohort. This model better stratified patient survival than the American Joint Committee on Cancer (AJCC) TNM staging system.

CONCLUSIONS

This novel nomogram with surgical margin, postoperative tumor node metastasis (pTNM) stage, and neural invasion as prognostic factors has a significant predictive performance for the risk of anastomotic recurrence after radical gastrectomy in patients with Siewert II or III adenocarcinoma.

How to identify early complications in patients undergoing distal gastrectomy?

In this editorial we comment on the article by Zhang et al published in a recent issue of the World Journal of Gastrointestinal Surgery. Gastrectomy with appropriate lymph node dissection is still standard curative treatment in locally advanced gastric cancer. Several studies point out that gastric cancer surgery is a complex procedure that leads to a high risk of morbidity and mortality. Many factors can contribute to the onset of complications with consequent effects on prognosis and increased mortality. The complications can be divided in complications related to anastomosis, to motility and to surgical site infection. The study presented by Zhang B et al represent an interesting analysis on the possibility to prevent postoperative morbidity. The study was performed on 131 patients with distal gastric cancer who underwent gastrectomy with D2 lymph node dissection. Of these patients, 16% developed early postoperative complications. The univariate analysis showed that prealbumin level, hypertension, diabetes, history of abdominal surgery, R0 resection, and blood transfusion were factors influencing early postoperative complications after distal gastrectomy. Moreover, the inclusion of the above significant variables in the logistic regression analysis revealed that hypertension, diabetes, a history of abdominal surgery, and blood transfusion were independent predictors of postoperative complications. In conclusion, preoperative and intraoperative factors can be used to establish an early postoperative nomogram model. The results of the study presented by Zhang et al suggest that the prediction model can be used to guide the detection of postoperative complications and has clinical reference value.

Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis

BACKGROUND

Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain.

AIM

To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence.

RESULTS

Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low.

CONCLUSIONS

This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.

Risk factors for liver dysfunction and their clinical importance after gastric cancer surgery

Postoperative hepatobiliary enzyme abnormalities often present as postoperative liver dysfunction in patients with gastric cancer (GC). This study aimed to identify the risk factors for postoperative liver dysfunction and their clinical impact after GC surgery. We retrospectively analyzed the data of 124 patients with GC who underwent laparoscopic or robotic surgery at Kyoto Prefectural University of Medicine between 2017 and 2019. Twenty (16.1%) patients with GC developed postoperative liver dysfunction (Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 ≥ Grade 3). Univariate analyses identified robotic surgery as a risk factor for postoperative liver dysfunction (P = 0.005). There was no correlation between the postoperative liver dysfunction status and postoperative complications or postoperative hospital stays. Patients with postoperative liver dysfunction did not have significantly worse overall survival (P = 0.296) or recurrence-free survival (P = 0.565) than those without postoperative liver dysfunction. Robotic surgery is a risk factor for postoperative liver dysfunction; however, postoperative liver dysfunction does not affect short or long-term outcomes.

Impact of severe postoperative complications on the prognosis of older patients with colorectal cancer: a two-center retrospective study

BACKGROUND

The occurrence of postoperative complications may affect short-term outcomes and prognosis of patients with various malignancies. However, the prognostic impact of these complications in older patients with colorectal cancer (CRC) remains unclear. Therefore, this study aimed to investigate the impact of severe postoperative complications on the oncological outcomes of older (aged ≥ 80 years) and non-older (aged < 80 years) patients with CRC.

METHODS

We retrospectively analyzed 760 patients with stage I-III CRC who underwent curative surgery in two institutions between 2013 and 2019. The patients were categorized into older (aged ≥ 80 years, 191 patients) and non-older (aged < 80 years, 569 patients) groups. Short- and long-term outcomes were compared between the two groups.

RESULTS

The incidence of severe postoperative complications did not differ between the two groups (p = 0.981). Cancer-specific survival (CSS) was significantly worse in older patients with severe complications than in those without severe complications (p = 0.007); meanwhile, CSS did not differ between the non-older patients with severe complications and those without severe complications. Survival analysis revealed that the occurrence of severe postoperative complications was an independent prognostic factor for CSS in older patients (hazard ratio = 4.00, 95% confidence interval: 1.27-12.6, p = 0.017).

CONCLUSION

CRC surgery can be safely performed in older and non-older patients. Moreover, the occurrence of severe postoperative complications might more strongly affect the prognosis of older patients than that of non-older patients.

Pre-operative psoas muscle index, a surrogate for sarcopenia; as a predictor of post-esophagectomy complications

BACKGROUND

Esophagectomy is the standard of care for curative esophageal cancer. However, it is associated with significant morbidity and mortality. Esophageal cancer is known to negatively affect the nutritional status of patients and many manifest cancer sarcopenia. At present, measures of sarcopenia involve complex and often subjective measurements. We assess whether the Psoas Muscle Index (PMI); an inexpensive, simple, validated method used to diagnose sarcopenia, can be used to predict adverse outcomes in patients after curative esophagectomy.

METHODS

Multi-centre, retrospective cohort between 2010-2020, involving all consecutive patients undergoing curative esophagectomy for esophageal cancer in University Malaya Medical Centre, Sungai Buloh Hospital, and Sultanah Aminah Hospital. The cut-off value differentiating low and normal PMI is defined as 443mm2/m2 in males and 326326 mm2/m2 in females. Complications were recorded using the Clavien-Dindo Scale.

RESULTS

There was no statistical correlation between PMI and major post-esophagectomy complications (p-value: 0.495). However, complication profile was different, and patients with low PMIs had higher 30-day mortality (21.7%) when compared with patients with normal PMI (8.1%) (p-value: 0.048).

CONCLUSIONS

Although PMI did not significantly predict post-esophagectomy complications, low PMI correlates with higher 30-day mortality, reflecting a lower tolerance for complications among these patients. PMI is a useful, inexpensive tool to identify sarcopenia and aids the patient selection process. This alerts healthcare professionals to institute intensive physiotherapy and nutritional optimization prior to esophagectomy.

Neoadjuvant Chemotherapy or Adjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma

BACKGROUND

Chemotherapy and chemoradiation have become essential adjuncts to improve the survival of patients with resectable esophageal squamous cell carcinoma (ESCC) in the perioperative period. Although preoperative treatment plus surgery is commonly used, controversy remains regarding the optimal treatment strategy for patients with locally advanced ESCC.

METHODS

A retrospective review of clinical stage II and III ESCC patients who underwent esophagectomy at Henan Cancer Hospital between October 2014 and October 2017 was performed. The patients were divided into a neoadjuvant chemotherapy (NAC) group and an adjuvant chemotherapy (AC) group. Propensity score matching (PSM) was used to exclude confounders. Survival was estimated using Kaplan‒Meier analysis and compared by the log-rank test. The Cox proportional hazards regression model was used for both the univariate and multivariate analyses.

RESULTS

A total of 684 patients were enrolled, including 365 (53.4%) patients in the NAC group. After PSM, 294 pairs of patients were left. NAC prolonged the OS (not reached versus 57.3 months, P = 0.002) and DFS (57.2 vs. 36.4 months, P = 0.010) and decreased the total rate of recurrence (50.1% vs. 59.2%, P = 0.025) and local recurrence (27.9% vs. 36.7%, P = 0.022) compared with AC. The multivariable analyses showed that NAC plus surgery modality was an independent predictor for improved OS (HR: 0.582, 95% CI: 0.467-0.786, P = 0.001).

CONCLUSION

NAC plus surgery prolonged OS and DFS, and significantly decreased the total rate of recurrence compared with surgery plus AC in patients with clinical stage II and III ESCC.

Long-term survival is not affected by severity of complications following esophagectomy

INTRODUCTION

Outcomes following esophagectomy for esophageal cancer have continued to improve over the last 30 years. Post-operative complications impact upon peri-operative and short-term survival but the effect on long-term survival remains debated. This study aims to investigate the effect of post-operative complications on long-term survival following esophagectomy.

MATERIALS AND METHODS

All patients who underwent an esophagectomy between January 2010 and January 2019 were included from a single high-volume center. Data was collected contemporaneously. Patients were separated into three groups; those who experienced no, or very minor complications (Clavien-Dindo 0 or 1), minor complications (Clavien-Dindo 2), and major complications (Clavien-Dindo 3-4), at 30 days. To correct for short-term mortality effects, those who died during the index hospital admission were excluded. Overall survival was analyzed using Kaplan-Meier and log rank testing.

RESULTS

The study cohort comprised 721 patients. There were 42.4% (306/721), 29.5% (213/721) and 25.7% (185/721) in the Clavien-Dindo 0-1, Clavien-Dindo 2, and Clavien-Dindo 3-4 group respectively. Seventeen patients (2.4%) died during their index hospital admission and were therefore excluded. There was no significant difference between median survival across the 3 groups (50, 57 and 52 months). Across all 3 groups, overall long-term survival rates were equivalent at 1 (87.5%, 84.9%, 83.2%), 3 (59.7%, 59.6%, 54.2%), and 5 years (43.9%, 48.9%, 45.7%) (p = 0.806). The only factors independently associated with survival in this cohort, were male gender, Charlson comorbidity index, and overall pathological stage of disease.

CONCLUSION

Long-term survival is not affected by peri-operative complications, irrespective of severity, following esophagectomy. Further study into the long-term quality of life is required.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer

BACKGROUND

Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission.

METHODS

All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest.

RESULTS

Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32).

CONCLUSIONS

AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Evaluation of factors influencing long-term and textbook outcomes in laparoscopic gastrectomy

BACKGROUND

Textbook outcome (TO) in gastric cancer surgery is a multidimensional measure of surgical quality. However, its impact on long-term survival after laparoscopic gastrectomy (LG) is unclear. This study aims to evaluate TO in LG, assess its hospital-level relevance, and examine its association with long-term survival.

METHODS

In this retrospective cohort study, we analyzed 2278 consecutive gastric cancer patients who underwent laparoscopic gastrectomy (LG) from January 2004 to December 2017. We determined TO achievement rates, compared preoperative and intraoperative variables between TO and non-TO groups, identified independent predictors of TO, and assessed long-term oncologic outcomes using Kaplan-Meier analysis and Cox regression.

RESULTS

A total of 1540 LG patients were analyzed, with 994 (64.5%) achieving TO. The least frequently achieved metric was 'hospital stays ≤21 days' (83.4%), followed by 'lymph nodes retrieved ≥15' (84.0%). Factors independently associated with reduced TO likelihood included age ≥65 years, BMI ≥25, ASA III, conversion to open surgery, operation time ≥260 min, and estimated blood loss ≥150 ml. Furthermore, TO was independently linked to improved 5-year overall survival (OS) and disease-free survival (DFS) (HR 0.519 [0.443-0.609] and HR 0.517 [0.443-0.604], respectively).

CONCLUSION

Implementing the TO concept in LG provides a benchmark for achieving improved prognoses and empowers surgeons to devise strategies for enhancing surgical care quality.

Milestones in the History of Esophagectomy: From Torek to Minimally Invasive Approaches

The history of esophagectomy reflects a journey of dedication, collaboration, and technical innovation, with ongoing endeavors aimed at optimizing outcomes and reducing complications. From its early attempts to modern minimally invasive approaches, the journey has been marked by perseverance and innovation. Franz J. A. Torek's 1913 successful esophageal resection marked a milestone, demonstrating the feasibility of transthoracic esophagectomy and the potential for esophageal cancer cure. However, its high mortality rate posed challenges, and it took almost two decades for similar successes to emerge. Surgical techniques evolved with the left thoracotomy, right thoracotomy, and transhiatal approaches, expanding the indications for resection. Mechanical staplers introduced in the early 20th century transformed anastomosis, reducing complications. The advent of minimally invasive techniques in the 1990s aimed to minimize complications while maintaining oncological efficacy. Robot-assisted esophagectomy further pushed the boundaries of minimally invasive surgery. Collaborative efforts, particularly from the Worldwide Esophageal Cancer Collaboration and the Esophageal Complications Consensus Group, standardized reporting and advanced the understanding of outcomes. The introduction of risk prediction models aids in making informed decisions. Despite significant improvements in survival rates and postoperative mortality, anastomotic leaks remain a concern, with recent rates showing an increase. Prevention strategies include microvascular anastomosis and ischemic preconditioning, yet challenges persist.

The safety of digestive tract cancer surgery during COVID-19: A living systematic review and meta-analysis

Surgery is the primary curative treatment of solid cancers. However, its safety has been compromised by the outbreak of COVID-19. Therefore, it is necessary to evaluate the safety of digestive tract cancer surgery in the context of COVID-19. We used the Review Manager software (v.5.4) and Stata software (version 16.0) for meta-analysis and statistical analysis. Sixteen retrospective studies involving 17,077 patients met the inclusion criteria. The data indicates that performing digestive tract cancer surgery during the COVID-19 pandemic led to increased blood loss(MD = -11.31, 95%CI:-21.43 to -1.20, P = 0.03), but did not increase postoperative complications(OR = 1.03, 95%CI:0.78 to1.35, P = 0 0.86), anastomotic leakage (OR = 0.96, 95%CI:0.52 to1.77, P = 0 0.89), postoperative mortality (OR = 0.65, 95%CI:0.40 to1.07, P = 0 0.09), number of transfusions (OR = 0.74, 95%CI:0.30 to 1.80, P = 0.51), number of patients requiring ICU care(OR = 1.37, 95%CI:0.90 to 2.07, P = 0.14), postoperative 30-d readmission (OR = 0.94, 95%CI:0.82 to 1.07, P = 0 0.33), total hospital stay (MD = 0.11, 95%CI:-2.37 to 2.59, P = 0.93), preoperative waiting time(MD = - 0.78, 95%CI:-2.34 to 0.79, P = 0.33), postoperative hospital stay(MD = - 0.44, 95%CI:-1.61 to 0.74, P = 0.47), total operation time(MD = -12.99, 95%CI:-28.00 to 2.02, P = 0.09) and postoperative ICU stay (MD = - 0.02, 95%CI:-0.62 to 0.57, P = 0.94). Digestive tract cancer surgery can be safely performed during the COVID-19.

Clinical predictors of early postoperative recurrence after radical esophagectomy for thoracic esophageal cancer

PURPOSE

Esophagectomy for esophageal cancer has a high incidence rate of early postoperative recurrence and death. This study aimed to identify the clinical and pathological features in early recurrence cases and to confirm the usefulness of prediction using these factors for effective adjuvant therapy and postoperative surveillance.

METHODS

One hundred and twenty five patients who developed postoperative recurrence after undergoing radical esophagectomy for thoracic esophageal cancer were classified into two groups as follows: those with early recurrence at ≤ 6 months and those with nonearly recurrence at > 6 months after surgery. After identifying related factors of early recurrence, usefulness of these factors for prediction were examined in all patients with and without recurrence.

RESULTS

The analysis cohort consisted of 43 and 82 patients in the early and nonearly recurrence groups, respectively. In multivariate analysis, factors associated with early recurrence were higher initial levels of tumor markers (squamous cell carcinoma [SCC] ≥ 1.5 ng/ml in tumors, except for adenocarcinoma, and carcinoembryonic antigen [CEA] ≥ 5.0 ng/ml in adenocarcinoma) and higher venous invasion (v), i.e., ≥ 2 (p = 0.040 and p = 0.004, respectively). The usefulness of these two factors for recurrence prediction was confirmed in 378 patients, including 253 patients without recurrence. Patients with at least one of the two factors had significantly higher early recurrence rates than those without any factors in pStages II and III (odds ratio [OR], 6.333; p = 0016 and OR, 4.346; p = 0.008, respectively).

CONCLUSIONS

Early recurrence of thoracic esophageal cancer (i.e., during ≤ 6 months after esophagectomy) was associated with higher initial tumor marker levels and pathological findings of v ≥ 2. The combination of these two factors is useful as a simple and critical predictor of early postoperative recurrence.

Short-term and long-term effects of recurrent laryngeal nerve injury after robotic esophagectomy

BACKGROUND

Robot-assisted minimally invasive esophagectomy (RAMIE) was reported to have superiority in upper mediastinal lymph nodes dissection than traditional approach, but related injuries to recurrent laryngeal nerve (RLNI) cannot be avoided. Considering that there is no study centering on RLNI during robotic manipulation, this study aimed to investigate the impact of RLNI on the short-term and long-term outcomes after RAMIE.

METHODS

Patients with esophageal cancer (EC) who underwent RAMIE from June 2015 to July 2019 were collated from a prospectively maintained database. Short-term and long-term outcomes of RLNI were analyzed.

RESULTS

A total of 409 patients were included with the incidence of RLNI being 18.6% (76/409). A higher rate of postoperative pulmonary complications including pneumonia (P < 0.001) and acute respiratory distress syndrome (ARDS) (P = 0.041) was associated with RLNI, requiring more interventions for bronchoscopy airway suction (P < 0.001), tracheal reintubation (P = 0.013) and tracheostomy (P < 0.001). Patients with RLNI had a prolonged length of hospitalization and intensive care unit (ICU) stay (P < 0.001). With the median follow-up time of 48.7 (interquartile range [IQR]:27.6-60.9) months, recurrence in regional lymph nodes at mediastinum did not differ between groups (P = 0.351). Similarly, the Kaplan-Meier curves revealed no significant divergency for overall survival after RLNI (P = 0.452).

CONCLUSIONS

RLNI after robotic esophagectomy is a serious morbidity associated with an increased rate of pulmonary complications, prolonged length of hospitalization with limited influence on long-term prognosis.

New scoring system combining computed tomography body composition analysis and inflammatory-nutritional indicators to predict postoperative complications in stage II-III colon cancer

BACKGROUND AND AIM

Postoperative complications are important clinical outcomes for colon cancer patients. This study aimed to investigate the predictive value of inflammatory-nutritional indicators combined with computed tomography body composition on postoperative complications in patients with stage II-III colon cancer.

METHODS

We retrospectively collected data from patients with stage II-III colon cancer admitted to our hospital from 2017 to 2021, including 198 patients in the training cohort and 50 patients in the validation cohort. Inflammatory-nutritional indicators and body composition were included in the univariate and multivariate analyses. Binary regression was used to develop a nomogram and evaluate its predictive value.

RESULTS

In the multivariate analysis, the monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), nutritional risk score (NRS), skeletal muscle index (SMI), and visceral fat index (VFI) were independent risk factors for postoperative complications of stage II-III colon cancer. In the training cohort, the area under the receiver operating characteristic curve of the predictive model was 0.825 (95% confidence interval [CI] 0.764-0.886). In the validation cohort, it was 0.901 (95% CI 0.816-0.986). The calibration curve showed that the prediction results were in good agreement with the observational results. Decision curve analysis showed that colon cancer patients could benefit from the predictive model.

CONCLUSIONS

A nomogram combining MLR, SII, NRS, SMI, and VFI with good accuracy and reliability in predicting postoperative complications in patients with stage II-III colon cancer was established, which can help guide treatment decisions.

Feeding gastrostomy and duodenostomy using the round ligament of the liver versus conventional feeding jejunostomy after esophagectomy: a meta-analysis

Esophageal cancer patients require enteral nutritional support after esophagectomy. Conventional feeding enterostomy to the jejunum (FJ) is occasionally associated with small bowel obstruction because the jejunum is fixed to the abdominal wall. Feeding through an enteral feeding tube inserted through the reconstructed gastric tube (FG) or the duodenum (FD) using the round ligament of the liver have been suggested as alternatives. This meta-analysis aimed to compare short-term outcomes between FG/FD and FJ. Studies published prior to May 2022 that compared FG or FD with FJ in cancer patients who underwent esophagectomy were identified via electronic literature search. Meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate Odds Ratios (ORs) with 95% confidence intervals (CIs). Five studies met inclusion criteria to yield a total of 1687 patients. Compared with the FJ group, the odds of small bowel obstruction (OR 0.09; 95% CI, 0.02-0.33), catheter site infection (OR 0.18; 95% CI, 0.06-0.51) and anastomotic leakage (OR 0.53; 95% CI, 0.32-0.89) were lower for the FG/FD group. Odds of pneumonia, recurrent laryngeal nerve palsy, chylothorax and hospital mortality did not significantly differ between the groups. The length of hospital stay was shorter for the FG/FD group (median difference, -10.83; 95% CI, -18.55 to -3.11). FG and FD using the round ligament of the liver were associated with lower odds of small bowel obstruction, catheter site infection and anastomotic leakage than FJ in esophageal cancer patients who underwent esophagectomy.

Primary Surgery Not Inferior to Neoadjuvant Chemoradiotherapy for Esophageal Adenocarcinoma

BACKGROUND

The current gold standard for treatment of locally advanced esophageal adenocarcinoma is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery. The shift toward neoadjuvant chemoradiotherapy (nCRT) was driven by the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. This study reassessed, in daily practice, the presumed advantage of nCRT followed by surgery on long-term survival compared with primary surgery, in a group of all adenocarcinomas treated through a transthoracic approach with extensive 2-field lymphadenectomy.

METHODS

This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT1/2 N+ or cT3/4 N0/+). For appropriate comparison, exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. The primary end point was 5-year overall survival.

RESULTS

There were 473 eligible patients who underwent primary surgery (225 patients) or nCRT + surgery (248 patients). After propensity score-matched analysis, 149 matched cases were defined in each group for analysis. There was no significant difference after 5 years between the matched groups in median overall survival (32.5 and 35.0 months, P = .41) and median disease-free survival (14.3 and 13.5 months, P = .16). nCRT was associated with significantly more postoperative complications (mean Comprehensive Complication Index score: 21.0 vs 30.5, P < .0001) and longer mean stay in the hospital (14.0 vs 18.2 days, P = .05) and intensive care unit (11.7 vs 37.7 days, P = .05).

CONCLUSIONS

Our propensity score-matched results indicate that primary surgery, performed through transthoracic approach with extensive 2-field lymphadenectomy, can offer a comparable overall and disease-free survival after 5 years, with potentially fewer postoperative complications and shorter hospital and intensive care unit stay compared with nCRT followed by surgery.

Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon

BACKGROUND

Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models.

METHODS

Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes.

RESULTS

Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models.

CONCLUSION

Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.

Survival impact of surgical site infection in esophageal cancer surgery: A multicenter retrospective cohort study

Aim

This study was performed to evaluate the oncological impact of surgical site infection (SSI) and pneumonia on long-term outcomes after esophagectomy.

Methods

The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 407 patients with curative stage I/II/III esophageal cancer at 11 centers from April 2013 to March 2015. We investigated the association of SSI and postoperative pneumonia with oncological outcomes in terms of relapse-free survival (RFS) and overall survival (OS).

Results

Ninety (22.1%), 65 (16.0%), and 22 (5.4%) patients had SSI, pneumonia, and both SSI and pneumonia, respectively. The univariate analysis demonstrated that SSI and pneumonia were associated with worse RFS and OS. In the multivariate analysis, however, only SSI had a significant negative impact on RFS (HR, 1.63; 95% confidence interval, 1.12-2.36; P = 0.010) and OS (HR, 2.06; 95% confidence interval, 1.41-3.01; P < 0.001). The presence of both SSI and pneumonia and the presence of severe SSI had profound negative oncological impacts. Diabetes mellitus and an American Society of Anesthesiologists score of III were independent predictive factors for both SSI and pneumonia. The subgroup analysis showed that three-field lymph node dissection and neoadjuvant therapy canceled out the negative oncological impact of SSI on RFS.

Conclusion

Our study demonstrated that SSI, rather than pneumonia, after esophagectomy was associated with impaired oncological outcomes. Further progress in the development of strategies for SSI prevention may improve the quality of care and oncological outcomes in patients undergoing curative esophagectomy.

Reconstruction using the colon or jejunum in patients with synchronous advanced esophageal and gastric cancers: a retrospective study from a single institutional database

PURPOSE

The aim of this study was to evaluate the feasibility and efficacy of simultaneous resection of synchronous advanced esophageal and gastric cancers.

METHODS

We retrospectively analyzed the clinical data of 16 patients who underwent resection of synchronous advanced esophageal squamous cell carcinoma (ESCC) and gastric adenocarcinoma from January 2009 to Dec 2021. Subtotal esophagectomy and total gastrectomy were performed using the Ivor-Lewis or McKeown approach. Reconstruction was performed using a pedicled jejunal graft or colon interposition. Perioperative and postoperative data of all patients were analyzed.

RESULTS

There were no in-hospital mortalities following surgery, but 9 patients (56.3%) suffered major perioperative complications. Comparison of the groups that received reconstruction using the jejunum and the colon indicated similar incidences of perioperative complications, overall survival, and disease-free survival. Cox regression analysis indicated that lymph node metastasis of both cancers was independent risk factor for overall survival.

CONCLUSION

The existence of synchronous tumors of the esophagus and stomach is not unusual, the radical surgical treatment could be carried out whenever possible.

The association between postoperative complications and long-term survival after esophagectomy: a multicenter cohort study

Conflicting results are reported on the association between post-esophagectomy complications and long-term survival. This multicenter study assesses the association between complications after an esophagectomy and long-term overall survival. Five Dutch high-volume centers collected data from consecutive patients undergoing esophagectomy between 2010 and 2016 and merged these with long-term survival data from the Netherlands Cancer Registry. Exclusion criteria were non-curative resections and 90-day mortality, among others. Primary outcome was overall survival related to the presence of a postoperative complication in general. Secondary outcomes analyzed the presence of anastomotic leakage and cardiopulmonary complications. Propensity score matching was performed and the outcomes were analyzed via Log-Rank test and Kaplan Meier analysis. Among the 1225 patients included, a complicated course occurred in 719 patients (59.0%). After matching for baseline characteristics, 455 pairs were successfully balanced. Patients with an uncomplicated postoperative course had a 5-year overall survival of 51.7% versus 44.4% in patients with complications (P = 0.011). Anastomotic leakage occurred in 18.4% (n = 226), and in 208 matched pairs, it was shown that the 5-year overall survival was 57.2% in patients without anastomotic leakage versus 44.0% in patients with anastomotic leakage (P = 0.005). Overall cardiopulmonary complication rate was 37.1% (n = 454), and in 363 matched pairs, the 5-year overall survival was 52.1% in patients without cardiopulmonary complications versus 45.3% in patients with cardiopulmonary complications (P = 0.019). Overall postoperative complication rate, anastomotic leakage, and cardiopulmonary complications were associated with a decreased long-term survival after an esophagectomy. Efforts to reduce complications might further improve the overall survival for patients treated for esophageal carcinoma.

Impact of Robot-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Propensity Score-Matched Short-Term Analysis

Background

We compared short-term clinical outcomes between robotic-assisted minimally invasive esophagectomy (RAMIE) and video-assisted thoracic esophagectomy (VATS-E) using propensity score-matched analysis.

Methods

We enrolled 114 patients with esophageal cancer who underwent esophagectomy at our institution from January 2013 to January 2022. Propensity score matching was performed to minimize selection bias between the RAMIE and VATS-E groups.

Results

After propensity score matching, 72 patients (RAMIE group, n = 36; VATS-E group, n = 36) were selected for analysis. No significant differences in clinical variables were observed between the two groups. The RAMIE group had a significantly longer thoracic operation time (313 ± 40 vs. 295 ± 35 min, P = 0.048), a higher number of right recurrent laryngeal nerve lymph nodes (4.2 ± 2.7 vs. 2.9 ± 1.9, P = 0.039), and a shorter postoperative hospital stay (23.2 ± 12.8 vs. 30.4 ± 18.6 days, P = 0.018) than the VATS-E group. The RAMIE group tended to have a lower rate of anastomotic leakage (13.9% vs. 30.6%) than the VATS-E group, although the difference was not statistically significant (P = 0.089). No significant differences were found in recurrent laryngeal nerve paralysis (11.1% vs. 13.9%, P = 0.722) or pneumonia (13.9% vs. 13.9%, P = 1.000) between the RAMIE group and the VATS-E group.

Conclusion

Although RAMIE for esophageal cancer requires a longer thoracic surgery time, it might be a feasible and safe alternative to VATS-E for treating esophageal cancer. Further analysis is needed to clarify the advantages of RAMIE over VATS-E, especially in terms of long-term surgical outcomes.

Postoperative liver dysfunction is associated with poor long-term outcomes in patients with colorectal cancer: a retrospective cohort study

BACKGROUND

Postoperative hepatobiliary enzyme abnormalities often present as postoperative liver dysfunction in patients with colorectal cancer. This study aimed to clarify the risk factors of postoperative liver dysfunction and its prognostic impact following colorectal cancer surgery.

METHODS

We retrospectively analyzed data from 360 consecutive patients who underwent radical resection for Stage I-IV colorectal cancer between 2015 and 2019. A subset of 249 patients with Stage III colorectal cancer were examined to assess the prognostic impact of liver dysfunction.

RESULTS

Forty-eight (13.3%) colorectal cancer patients (Stages I-IV) developed postoperative liver dysfunction (Common Terminology Criteria for Adverse Events version 5.0 CTCAE v5.0 ≥ Grade 2). Univariate and multivariate analyses identified the liver-to-spleen ratio on preoperative plain computed tomography (L/S ratio; P = 0.002, Odds ratio 2.66) as an independent risk factor for liver dysfunction. Patients with postoperative liver dysfunction showed significantly poorer disease-free survival than patients without liver dysfunction (P < 0.001). Univariate and multivariate analyses using Cox's proportional hazards model revealed that postoperative liver dysfunction independently was a poor prognostic factor (P = 0.001, Hazard ratio 2.75, 95% CI: 1.54-4.73).

CONCLUSIONS

Postoperative liver dysfunction was associated with poor long-term outcomes in patients with Stage III colorectal cancer. A low liver-to-spleen ratio on preoperative plain computed tomography images was an independent risk factor of postoperative liver dysfunction.

The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma

BACKGROUND

Esophagectomy for esophageal carcinoma is associated with higher morbidity and mortality rates than other gastrointestinal surgeries. Smoking is an established risk factor for postoperative complications after esophagectomy. This study aimed retrospectively to investigate the impact of smoking status on short- and long-term outcomes for patients undergoing thoracoscopic esophagectomy in the prone position (TEP) for esophageal carcinoma.

METHODS

In this study, 234 patients with esophageal carcinoma who underwent TEP between 2012 and 2020 were divided into two groups based on smoking status (current or non-current smokers and the Brinkman index) by patients' declarations. Postoperative complications (Clavien-Dindo classification grade ≥2), overall survival (OS), and disease-free survival (DFS) were compared between smoking statuses.

RESULTS

The rates of postoperative complications did not differ significantly between the two groups (current smoker vs non-current smoker; Brinkman index ≥800 vs <800). The rate of postoperative pneumonia was higher in the combination group of current and higher Brinkman index (≥800) smokers than in the other group (25.0 % vs 11.8 %; P = 0.036). Multivariate analysis showed that smoking status was an independent risk factor for postoperative pneumonia (hazard ratio, 0.41; 95 % confidence interval, 0.18-0.93; P = 0.037). According to the long-term outcomes, no significant differences in OS and DFS were observed between the smoking statuses.

CONCLUSIONS

The combination of current smoking and heavy smoking history is a risk factor for postoperative pneumonia in patients who have esophageal carcinoma treated with TEP, although no correlation was observed between the long-term outcomes and smoking status.

Inflammatory and Nutritional Status Influences Outcomes of Minimally Invasive Esophagectomy

INTRODUCTION

The potential association between severe postoperative complications (SPC) and the oncological outcomes of esophageal squamous cell carcinoma (ESCC) patients according to the different Naples Prognostic Score (NPS) of the inflammatory nutritional status after minimally invasive esophagectomy (MIE) is unclear.

METHODS

Kaplan-Meier survival analysis was used to evaluate overall survival (OS) and disease-free survival (DFS) between with or without SPC (Clavien-Dindo grade ≥ III) in low NPS status (NPS = 0 or 1) and high NPS status (NPS = 2 or 3 or 4) patients. Cox multivariable analysis was carried out to analyze the various independent factors of OS and DFS, and a nomogram based on SPC was established.

RESULTS

A total of 20.7% (125/604) ESCC patients developed SPC after MIE. Patients with SPC exhibited poor 5-year OS and DFS compared to those without SPC (all P < 0.001). Further analysis revealed that SPC significantly reduced OS and DFS in patients with high NPS status (all P < 0.001) but had little effect on the prognosis of patients with low NPS status (all P > 0.05). Multivariable Cox analysis revealed that SPC could be an independent influence indicator for OS and DFS in patients with high NPS status. Therefore, a novel nomogram combining SPC and tumor-node-metastasis (TNM) staging has been developed, which was found to be relatively more accurate in predicting OS and DFS than TNM staging alone.

CONCLUSION

Severe complications can adversely affect the long-term oncological outcome of ESCC patients with high systemic inflammatory response and malnutrition after MIE.

Extension of lymph node dissection in the surgical treatment of esophageal and gastroesophageal junction cancer: seven questions and answers

The role of two- or three-field nodal dissection in the surgical treatment of esophageal and gastroesophageal junction cancer in the minimally invasive era is still controversial. This review aims to clarify the extension of nodal dissection in esophageal and gastroesophageal junctional cancer. A basic evidence-based analysis was designed, and seven research questions were formulated and answered with a narrative review. Reports with little or no data, single cases, small series and review articles were not included. Three-field lymph node dissection improves staging accuracy, enhances locoregional disease control and might improve survival in the group of patients with cervical and upper mediastinal metastatic lymph nodal involvement from middle and proximal-third esophageal cancer.

Esophagectomy Complications Impact Long-term Survival: A National Cancer Database Analysis

OBJECTIVE

To determine the effect of prolonged length of stay (LOS) after esophagectomy on long term survival.

BACKGROUND

Complications after esophagectomy have a significant impact in short-term survival. The specific effect of prolonged LOS after esophagectomy is unclear. We hypothesized that postoperative complications that occur after esophagectomy, resulting in prolonged LOS, have a detrimental effect on long term survival.

METHODS

All patients undergoing esophagectomy between 2004 and 2014 were identified in the National Cancer Database. To eliminate the confounding effect of short-term mortality, we included only patients who survived at least 90 days postoperatively. Demographics, disease characteristics, and perioperative outcomes were analyzed. Postoperative LOS was used as a surrogate for postoperative complications. The highest quintile of LOS was defined as excessive LOS (ELOS). Kaplan-Meier and Cox proportional hazards survival analyses were performed to examine survival.

RESULTS

A total of 20,719 patients were identified. Of those 3826 had ELOS, with median LOS 26days (range 18-168days). Their median survival was 30.6 months compared to 53.6 months in the entire non-ELOS group (P < 0.0001). After multivariate analysis ELOS (odds ratio 1.56, 95% confidence interval 1.46-1.67) was an independent predictor of overall mortality. Higher disease stage, higher age, male sex, higher Charlson/Deyo comorbidity score, and readmission after discharge were also significant negative predictors of long-term survival, whereas surgery in an academic institution, being at the highest income quartile and having private or Medicare insurance predicted longer survival (all P < 0.001).

CONCLUSIONS AND RELEVANCE

Postoperative complications after esophagectomy, resulting in ELOS, predict lower long-term survival independent of other factors. Counseling patients about surgery should include the detrimental long-term effects of postoperative complications and ELOS. Avoiding ELOS (LOS exceeding 18 days) could be considered a quality metric after esophagectomy.

Effect of Thoracic Surgery Regionalization on 1- and 3-Year Survival after Cancer Esophagectomy

OBJECTIVE

The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the United States translated to longer-term survival benefit.

BACKGROUND

Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival are mixed.

METHODS

We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and chi-square tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality.

RESULTS

Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% vs 73.9%, P = 0.02) but not 3-year survival (52.9% vs 58.2%, P = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.29-1.00], and only thoracic specialty at 3years (OR 0.62, 95% CI 0.38-0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model.

CONCLUSIONS

Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.

Emerging precision neoadjuvant systemic therapy for patients with resectable non-small cell lung cancer: current status and perspectives

Over the past decade, targeted therapy for oncogene-driven NSCLC and immune checkpoint inhibitors for non-oncogene-driven NSCLC, respectively, have greatly improved the survival and quality of life for patients with unresectable NSCLC. Increasingly, these biomarker-guided systemic therapies given before or after surgery have been used in patients with early-stage NSCLC. In March 2022, the US FDA granted the approval of neoadjuvant nivolumab and chemotherapy for patients with stage IB-IIIA NSCLC. Several phase II/III trials are evaluating the clinical efficacy of various neoadjuvant immune checkpoint inhibitor combinations for non-oncogene-driven NSCLC and neoadjuvant molecular targeted therapies for oncogene-driven NSCLC, respectively. However, clinical application of precision neoadjuvant treatment requires a paradigm shift in the biomarker testing and multidisciplinary collaboration at the diagnosis of early-stage NSCLC. In this comprehensive review, we summarize the current diagnosis and treatment landscape, recent advances, new challenges in biomarker testing and endpoint selections, practical considerations for a timely multidisciplinary collaboration at diagnosis, and perspectives in emerging neoadjuvant precision systemic therapy for patients with resectable, early-stage NSCLC. These biomarker-guided neoadjuvant therapies hold the promise to improve surgical and pathological outcomes, reduce systemic recurrences, guide postoperative therapy, and improve cure rates in patients with resectable NSCLC.

Relationship between laparoscopic total gastrectomy-associated postoperative complications and gastric cancer prognosis

This study aimed to investigate the incidence and prognosis of postoperative complications after laparoscopic total gastrectomy (LTG) for gastric cancer (GC). We retrospectively enrolled 411 patients who underwent curative LTG for GC at seven institutions between January 2004 and December 2018. The patients were divided into two groups, complication group (CG) and non-complication group (non-CG), depending on the presence of serious postoperative complications (Clavien-Dindo grade III [≥ CD IIIa] or higher complications). Short-term outcomes and prognoses were compared between two groups. Serious postoperative complications occurred in 65 (15.8%) patients. No significant difference was observed between the two groups in the median operative time, intraoperative blood loss, number of lymph nodes harvested, or pathological stage; however, the 5-year overall survival (OS; CG 66.4% vs. non-CG 76.8%; p = 0.001), disease-specific survival (DSS; CG 70.1% vs. non-CG 76.2%; p = 0.011), and disease-free survival (CG 70.9% vs. non-CG 80.9%; p = 0.001) were significantly different. The Cox multivariate analysis identified the serious postoperative complications as independent risk factors for 5-year OS (HR 2.143, 95% CI 1.165-3.944, p = 0.014) and DSS (HR 2.467, 95% CI 1.223-4.975, p = 0.011). A significant difference was detected in the median days until postoperative recurrence (CG 223 days vs. non-CG 469 days; p = 0.017) between the two groups. Serious postoperative complications after LTG negatively affected the GC prognosis. Efforts to decrease incidences of serious complications should be made that may help in better prognosis in patients with GC after LTG.

Improved Preoperative Risk Assessment Tools Are Needed to Guide Informed Decision Making before Esophagectomy

OBJECTIVE

We sought to evaluate the performance of 2 commonly used prediction models for postoperative morbidity in patients undergoing open and minimally invasive esophagectomy.

SUMMARY BACKGROUND DATA

Patients undergoing esophagectomy have a high risk of postoperative complications. Accurate risk assessment in this cohort is important for informed decision-making.

METHODS

We identified patients who underwent esophagectomy between January 2016 and June 2018 from our prospectively maintained database. Predicted morbidity was calculated using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (SRC) and a 5-factor National Surgical Quality Improvement Programderived frailty index. Performance was evaluated using concordance index (C-index) and calibration curves.

RESULTS

In total, 240 consecutive patients were included for analysis. Most patients (85%) underwent Ivor Lewis esophagectomy. The observed overall complication rate was 39%; the observed serious complication rate was 33%.The SRC did not identify risk of complications in the entire cohort (C-index, 0.553), patients undergoing open esophagectomy (C-index, 0.569), or patients undergoing minimally invasive esophagectomy (C-index, 0.542); calibration curves showed general underestimation. Discrimination of the SRC was lowest for reoperation (C-index, 0.533) and highest for discharge to a facility other than home (C-index, 0.728). Similarly, the frailty index had C-index of 0.513 for discriminating any complication, 0.523 for serious complication, and 0.559 for readmission.

CONCLUSIONS

SRC and frailty index did not adequately predict complications after esophagectomy. Procedure-specific risk-assessment tools are needed to guide shared patient-physician decision-making in this high-risk population.

Short- and long-term outcomes of thoracoscopic esophagectomy in the prone position for esophageal squamous cell carcinoma in patients with obstructive ventilatory disorder: a propensity score-matched study

BACKGROUND

Many patients with esophageal squamous cell carcinoma (ESCC) have obstructive ventilatory disorder (OVD), which is considered a risk factor for postoperative pneumonia. It has been reported that thoracoscopic esophagectomy in the prone position (TEP) is less invasive and is associated with fewer postoperative respiratory complications compared with open esophagectomy. This matched-cohort study aimed to elucidate the safety and oncologic outcomes of ESCC patients with OVD who undergo TEP.

METHODS

In this matched-cohort study, 237 patients with ESCC who underwent TEP between 2010 and 2018 were divided into two groups based on forced expiratory volume in 1 s/forced vital capacity. Postoperative complications (Clavien-Dindo classification grade II or higher), overall survival (OS), and disease-free survival (DFS) were compared between the two groups.

RESULTS

Based on their propensity scores, 75 patients with normal respiratory function (NRF) and 75 with OVD were selected. The rates of postoperative pneumonia were not significantly different between the two groups (NRF group vs OVD group: 18.7% vs 18.7%; P = 1.000). The rates of recurrent laryngeal nerve palsy and anastomotic leakage were also not significantly different (NRF group vs OVD group: 12.0% vs 18.7%, P = 0.365; 18.7% vs 18.7%, P = 1.000). The 5-year OS and DFS rates in the NRF vs OVD groups were 66.2% vs 54.9% and 63.5% vs 52.9%, respectively, with no significant differences (P = 0.421, 0.197).

CONCLUSIONS

TEP can be safely performed on ESCC patients with OVD and can result in an oncological efficiency equal to that of the NRF group.

Predictive role of preoperative geriatric nutritional risk index for clinical outcomes in surgical gastric cancer patients: A meta-analysis

PURPOSE

The association between the preoperative Geriatric Nutritional Risk Index (GNRI) and postoperative short-term and long-term clinical outcomes remains unclear. The aim of this meta-analysis was to identify the predictive role of the preoperative GNRI for postoperative clinical outcomes of gastric cancer patients based on current evidence.

METHODS

Several databases were searched up to July 28, 2022. The primary and secondary outcomes were long-term survival, including overall survival (OS), cancer-specific survival (CSS) and postoperative complications. Meanwhile, the hazard ratios (HRs) and relative risks (RRs) with 95% confidence intervals (CIs) were combined to assess the association of preoperative GNRI with postoperative survival and complications separately. The results Eight studies involving 4,189 patients were included, and they were all from Japan. The pooled results demonstrated that a lower preoperative GNRI was significantly related to worse OS (HR = 1.72, 95% CI: 1.18-2.53, P = 0.005) and CSS (HR = 1.67, 95% CI: 1.20-2.32, P = 0.002). Meanwhile, a lower preoperative GNRI was significantly associated with postoperative complications (RR = 1.97, 95% CI: 1.51-2.58, P < 0.001). Further analysis focusing on elderly patients showed similar results.

CONCLUSION

Preoperative GNRI is related to postoperative short-term and long-term clinical outcomes of Japanese gastric cancer patients, and a lower GNRI predicts poorer prognosis.

Dual-layer dual-energy CT for improving differential diagnosis of squamous cell carcinoma from adenocarcinoma at gastroesophageal junction

Objective

To examine the clinical values of dual-energy CT parameters derived from dual-layer spectral detector CT (SDCT) in the differential diagnosis of squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the gastroesophageal junction (GEJ).

Methods

Totally 66 patients with SCC and AC of the GEJ confirmed by pathological analysis were retrospectively enrolled, and underwent dual-phase contrast-enhancement chest CT with SDCT. Plain CT value, CT attenuation enhancement (△CT), iodine concentration (IC), spectral slope (λHU), effective atomic number (Zeff) and 40keV CT value (CT40keV) of the lesion in the arterial phase (AP) and venous phase (VP) were assessed. Multivariate logistic regression analysis was performed to evaluate the diagnostic efficacies of different combinations of dual-energy CT parameters. Receiver operating characteristic (ROC) curves were used to analyze the accuracy of dual-energy CT parameters and Delong test was used to compare AUCs.

Results

IC, λHU, Zeff and CT40keV in AP and VP and △CT in VP were significantly higher in the AC group than those in the SCC group (all P&lt;0.05). ROC curve analysis showed that IC, λHU, Zeff and CT40keV in VP had high diagnostic performances, with AUCs of 0.74, 0.74, 0.79 and 0.78, respectively. Logistic regression showed the combination of ICVP, λHU VP, CT40keV VP and Zeff VP had the highest AUC (0.84), with a threshold of 0.40, sensitivity and specificity in distinguishing SCC and AC were 93.1% and 73.0%, respectively. Delong test showed that the AUC of △CTVP was lower than other AUCs of dual-energy CT parameters.

Conclusion

Dual-energy CT parameters derived from SDCT provide added value in the differential diagnosis of SCC and AC of the GEJ, especially the combination of IC, λHU, CT40keV and Zeff in VP.

Advances in knowledge

Dual-energy CT parameters derived from dual-layer spectral detector CT provide added value to differentiate AC from SCC at the GEJ, especially the combination of effective atomic number, spectral slope, iodine concentration and 40keV CT value in VP.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition

Background

This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction.

Methods

Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes.

Results

Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030).

Conclusions

Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01704-x.

Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis

Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): -187.08 mL, 95% CI: [-283.81, -90.35]) and shorter hospital stays (WMD: -9.22 days, 95% CI: [-14.39, -4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.

Population-Based Cohort Study from a Prospective National Registry: Better Long-Term Survival in Esophageal Cancer After Minimally Invasive Compared with Open Transthoracic Esophagectomy

BACKGROUND

Recent research indicates long-term survival benefits of minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) for patients with esophageal and gastroesophageal junction (GEJ) cancers, but there is a need for more population-based studies.

METHODS

We conducted a prospective population-based nationwide cohort study including all patients in Sweden diagnosed with esophageal or junctional cancer who underwent a transthoracic esophagectomy with intrathoracic anastomosis. Data were collected from the Swedish National Register for Esophageal and Gastric Cancer in 2006-2019. Patients were grouped into OE and MIE including hybrid MIE (HMIE) and totally MIE (TMIE). Overall survival and short-term postoperative outcomes were compared using Cox regression and logistic regression models, respectively. All models were adjusted for age, sex, American Society of Anesthesiologists (ASA) score, clinical T and N stage, neoadjuvant therapy, year of surgery, and hospital volume.

RESULTS

Among 1404 patients, 998 (71.1%) underwent OE and 406 (28.9%) underwent MIE. Compared with OE, overall survival was better following MIE (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.55-0.94), TMIE (HR 0.67, 95% CI 0.47-0.94), and possibly also after HMIE (HR 0.76, 95% CI 0.56-1.02). MIE was associated with shorter operation time, less intraoperative bleeding, higher number of resected lymph nodes, and shorter hospital stay compared with OE. MIE was also associated with fewer overall complications (odds ratio [OR] 0.70, 95% CI 0.47-1.03) as well as non-surgical complications (OR 0.64, 95% CI 0.40-1.00).

CONCLUSIONS

MIE seems to offer better survival and similar or improved short-term postoperative outcomes in esophageal and GEJ cancers compared with OE in this unselected population-based cohort.

Clinical Features of Recurrence Pattern with Lung Metastasis After Radical Esophagectomy for Thoracic Esophageal Cancer

BACKGROUND

One of the difficulties in the treatment of esophageal cancer surgery is the high rate of postoperative recurrence. After esophagectomy, distant metastatic recurrence frequently occurs in the lung. This study aimed to determine the clinical features of a recurrence pattern with lung metastasis.

METHODS

The current study analyzed data from 138 patients who had postoperative recurrence of esophageal cancer after a radical esophagectomy. According to the recurrence pattern at the time of initial diagnosis, the patients were classified into two groups as follows: those with lung metastasis and those without.

RESULTS

Twenty-three of the 138 investigated patients had a recurrence pattern with lung metastasis. Salvage surgery and postoperative pneumonia (p = 0.041 and 0.030, respectively) were identified as risk factors for recurrence pattern with lung metastasis in multivariate analysis. When we compared the sites of primary esophageal tumors, we found that the frequencies of distant metastases, such as lung and liver metastases, as well as pleural/peritoneal dissemination, were higher in the mid and distal esophageal tumors. Patients with a recurrence pattern showing lung metastasis alone had a better overall and post-recurrence survival than those with other recurrence patterns (p < 0.001 and p < 0.001).

CONCLUSIONS

In patients who had postoperative recurrence after esophagectomy for thoracic esophageal cancer, salvage surgery, and postoperative pneumonia were significantly related to recurrence pattern with lung metastasis. Postoperative recurrence with lung metastasis alone had a better prognosis than other recurrence patterns; therefore, when pulmonary recurrence is suspected, performing intensive examinations for early diagnosis is critical.

The influence of minimally invasive esophagectomy versus open esophagectomy on postoperative pulmonary function in esophageal cancer patients: a meta-analysis

OBJECTIVE

To compare the influence of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on postoperative pulmonary function in patients with esophageal cancer.

METHODS

Studies about the influence of MIE and OE on postoperative pulmonary function in esophageal cancer patients were searched from PubMed, EMBASE, the Cochrane Library, CNKI, Chinese Science and Technology Journal Database, CBM, and Wanfang Data from inception to March 18, 2021. Meta-analysis was performed using the RevMan 5.3.

RESULTS

This analysis included eight studies, enrolling 264 patients who underwent MIE and 257 patients who underwent OE. The meta-analysis results showed that the MIE group had a higher outcome regarding the percent predicted vital capacity (%VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and maximum voluntary ventilation (MVV) 1 month after surgery than the OE group. In addition, those who underwent MIE had lower ΔVC%, ΔFVC, and ΔFEV1 between pre-operation and 1 month after surgery than those who underwent OE. There is no statistical difference between the two groups in ΔMVV.

CONCLUSION

Compared with OE, MIE has a more protective effect on postoperative pulmonary function. However, due to the small number of included literature and all cohort studies, this finding needs to be validated with larger samples and higher quality RCT studies.

Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis

Objective

Methods

Results

Conclusions

Preoperative neutrophil-to-lymphocyte ratio behaves as an independent prognostic factor even in patients with postoperative complications after curative resection for gastric cancer

PURPOSE

The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent.

METHODS

A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien-Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan-Meier method was used to assess overall survival.

RESULTS

The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien-Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p < 0.05). Patients with POC showed worse long-term survival (p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p < 0.001). Patients with preoperative NLR ≥ 2.4 (p = 0.02) had a worse prognosis. Multivariate analysis: pN (p < 0.001), postoperative complications (p < 0.001) (HR 3.04; 95% CI: 1.97-4.70) and NLR ≥ 2.4 (p = 0.04) (HR = 1.55; 95% CI: 1.02-2.3) were independent prognostic factors.

CONCLUSION

The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.