Safety and efficacy of minimally invasive McKeown esophagectomy in 1023 consecutive esophageal cancer patients: a single-center experience

Risk and management of adverse events in minimally invasive esophagectomy

Minimally invasive esophagectomy (MIE) has transformed esophageal surgery by reducing morbidity, accelerating recovery, and improving postoperative outcomes compared to traditional open esophagectomy. By utilizing techniques such as laparoscopic, thoracoscopic, and robotic-assisted approaches, MIE minimizes surgical trauma while maintaining oncological thoroughness. However, it also presents unique challenges, including risks of complications such as anastomotic leakage, pulmonary complications, and atrial fibrillation. Zhong et al developed and validated a risk stratification model for predicting surgical adverse events after MIE, enhancing preoperative assessment and patient management. This editorial further examines the advantages of MIE, its comparable oncological and long-term outcomes, as well as the incidence and contributing factors of postoperative complications. Emerging technologies, including machine learning models, intraoperative nerve monitoring, and robotic-assisted surgery, are highlighted as innovative solutions for risk prediction and prevention. Strategies such as enhanced recovery after surgery protocols and multidisciplinary collaboration are emphasized for their critical roles in minimizing complications and optimizing patient outcomes. By addressing these aspects, this editorial provides guidance to surgical teams in maximizing the benefits of MIE while effectively managing its associated risks.

Prediction and stratification for the surgical adverse events after minimally invasive esophagectomy: A two-center retrospective study

BACKGROUND

Minimally invasive esophagectomy (MIE) is a widely accepted treatment for esophageal cancer, yet it is associated with a significant risk of surgical adverse events (SAEs), which can compromise patient recovery and long-term survival. Accurate preoperative identification of high-risk patients is critical for improving outcomes.

AIM

To establish and validate a risk prediction and stratification model for the risk of SAEs in patients with MIE.

METHODS

This retrospective study included 747 patients who underwent MIE at two centers from January 2019 to February 2024. Patients were separated into a train set (n = 549) and a validation set (n = 198). After screening by least absolute shrinkage and selection operator regression, multivariate logistic regression analyzed clinical and intraoperative variables to identify independent risk factors for SAEs. A risk stratification model was constructed and validated to predict the probability of SAEs.

RESULTS

SAEs occurred in 10.2% of patients in train set and 13.6% in the validation set. Patients with SAE had significantly higher complication rate and a longer hospital stay after surgery. The key independent risk factors identified included chronic obstructive pulmonary disease, a history of alcohol consumption, low forced expiratory volume in the first second, and low albumin levels. The stratification model has excellent prediction accuracy, with an area under the curve of 0.889 for the training set and an area under the curve of 0.793 for the validation set.

CONCLUSION

The developed risk stratification model effectively predicts the risk of SAEs in patients undergoing MIE, facilitating targeted preoperative interventions and improving perioperative management.

Risk prediction model for postoperative pneumonia in esophageal cancer patients: A systematic review

Background

Numerous studies have developed or validated prediction models to estimate the likelihood of postoperative pneumonia (POP) in esophageal cancer (EC) patients. The quality of these models and the evaluation of their applicability to clinical practice and future research remains unknown. This study systematically evaluated the risk of bias and applicability of risk prediction models for developing POP in patients undergoing esophageal cancer surgery.

Methods

PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), WanFang Database and Chinese Biomedical Literature Database were searched from inception to March 12, 2024. Two investigators independently screened the literature and extracted data. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was employed to evaluate both the risk of bias and applicability.

Result

A total of 14 studies involving 23 models were included. These studies were mainly published between 2014 and 2023. The applicability of all studies was good. However, all studies exhibited a high risk of bias, primarily attributed to inappropriate data sources, insufficient sample size, irrational treatment of variables and missing data, and lack of model validation. The incidence of POP in patients undergoing esophageal cancer surgery ranged from 14.60% to 39.26%. The most frequently used predictors were smoking, age, chronic obstructive pulmonary disease(COPD), diabetes mellitus, and methods of thoracotomy. Inter-model discrimination ranged from 0.627 to 0.850, sensitivity ranged between 60.7% and 84.0%, and specificity ranged from 59.1% to 83.9%.

Conclusion

In all included studies, good discrimination was reported for risk prediction models for POP in patients undergoing esophageal cancer surgery, indicating stable model performance. However, according to the PROBAST checklist, all studies had a high risk of bias. Future studies should use the predictive model assessment tool to improve study design and develop new models with larger samples and multicenter external validation.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024527085.

Prediction of Morbidity and Mortality After Esophagectomy: A Systematic Review

BACKGROUND

Esophagectomy for esophageal cancer has a complication rate of up to 60%. Prediction models could be helpful to preoperatively estimate which patients are at increased risk of morbidity and mortality. The objective of this study was to determine the best prediction models for morbidity and mortality after esophagectomy and to identify commonalities among the models.

PATIENTS AND METHODS

A systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and was prospectively registered in PROSPERO ( https://www.crd.york.ac.uk/prospero/ , study ID CRD42022350846). Pubmed, Embase, and Clarivate Analytics/Web of Science Core Collection were searched for studies published between 2010 and August 2022. The Prediction model Risk of Bias Assessment Tool was used to assess the risk of bias. Extracted data were tabulated and a narrative synthesis was performed.

RESULTS

Of the 15,011 articles identified, 22 studies were included using data from tens of thousands of patients. This systematic review included 33 different models, of which 18 models were newly developed. Many studies showed a high risk of bias. The prognostic accuracy of models differed between 0.51 and 0.85. For most models, variables are readily available. Two models for mortality and one model for pulmonary complications have the potential to be developed further.

CONCLUSIONS

The availability of rigorous prediction models is limited. Several models are promising but need to be further developed. Some models provide information about risk factors for the development of complications. Performance status is a potential modifiable risk factor. None are ready for clinical implementation.

Immediate Postoperative High Syndecan-1 is Associated with Short-Term Morbidity and Mortality After Robot-Assisted Esophagectomy: A Prospective Observational Study

BACKGROUND

Disruption of the endothelial glycocalyx (EG) is associated with a poor prognosis in various clinical settings. This study aimed to determine the association between immediate postoperative serum syndecan-1 levels, a representative marker for EG degradation, and major postoperative morbidity and mortality in patients undergoing robot-assisted esophagectomy.

METHODS

Patients who underwent robot-assisted esophagectomy between 2018 and 2022 were prospectively enrolled. The primary outcome was the association between immediate postoperative syndecan-1 levels and the occurrence of major postoperative morbidity and mortality within 30 days of surgery. Patients were classified into low and high syndecan-1 groups based on the optimal cut-off value of syndecan-1 for predicting major morbidity and mortality. A multivariable logistic regression analysis was performed to investigate the risk factors for major morbidity and mortality.

RESULTS

A total of 207 patients were analyzed. Patients with high syndecan-1 levels (≥48 ng/mL) showed a significantly greater incidence of unexpected returns to the operating room and anastomotic leaks and longer durations of hospital and intensive care unit stays than patients with low syndecan-1 levels (<48 ng/mL). Immediate postoperative syndecan-1 levels ≥48 ng/mL (odds ratio [OR] 2.32, 95% confidence interval [CI] 1.23-4.76), American Society of Anesthesiologists physical status ≥III (OR 3.36, 95% CI 1.56-7.22), and current smoker (OR 4.02, 95% CI 1.52-10.61) were independently associated with major morbidity and mortality within 30 days of esophagectomy.

CONCLUSIONS

Immediate postoperative syndecan-1 levels ≥48 ng/mL could be used for the early detection of patients at high risk of complications after robot-assisted esophagectomy.

Primary membranous nephrotic syndrome with chylothorax as first presentation: A case report and literature review

BACKGROUND

Primary membranous nephrotic syndrome with chylothorax as the first manifestation is an unusual condition. To date, only a few cases have been reported in clinical practice.

CASE SUMMARY

The clinical data of a 48-year-old man with primary nephrotic syndrome combined with chylothorax admitted to the Department of Respiratory and Critical Care Medicine of Shaanxi Provincial People's Hospital were retrospectively analysed. The patient was admitted to the hospital for 12 d due to shortness of breath. Imaging showed pleural effusion, laboratory tests confirmed true chylothorax, and renal biopsy revealed membranous nephropathy. After primary disease treatment and early active symptom treatment, the prognosis of the patient was good. This case suggests that chylothorax is a rare complication of primary membranous nephrotic syndrome in adults, and early lymphangiography and renal biopsy can assist in the diagnosis when there are no contraindications.

CONCLUSION

Primary membranous nephrotic syndrome combined with chylothorax is rare in clinical practice. We report a relevant case to provide case information for clinicians and to improve diagnosis and treatment.

Which Anastomotic Techniques Is the Best Choice for Cervical Esophagogastric Anastomosis in Esophagectomy? A Bayesian Network Meta-Analysis

INTRODUCTION

The optimal choice of anastomotic techniques for cervical esophagogastric anastomosis in esophagectomy remains unclear.

METHODS

An electronic literature search of PubMed, Embase, and Web of Science (data up to April 2022) was conducted and screened to compare hand sewn (HS), circular stapling (CS), side-to-side linear stapling (LS), and triangulating stapling (TS) for cervical esophagogastric anastomosis. Anastomotic leak, pulmonary complications, anastomotic stricture, and reflux esophagitis of the 4 anastomotic techniques were evaluated using a Bayesian network meta-analysis by R.

RESULT

Twenty-nine studies were ultimately included, with a total of 5,020 patients from 9 randomized controlled trials, 7 prospect cohort studies, and 13 retrospective case-control studies in the meta-analysis. The present study demonstrates that the incidence of anastomotic leakage is lower in TS than HS and CS (TS vs. HS: odds ratio (OR) = 0.32, 95% CI: 0.1 to 0.9; TS vs. CS: OR = 0.37, 95% CI: 0.13 to 1.0), and the incidence of anastomotic stricture is lower in TS than in HS and CS (TS vs. HS: OR = 0.32, 95% CI: 0.11 to 0.86; TS vs. CS: OR = 0.23, 95% CI: 0.08 to 0.58). TS ranks best in terms of anastomotic leakage, pulmonary complication, anastomotic stricture, and reflux esophagitis.

CONCLUSION

TS for cervical esophagogastric anastomosis of esophagectomy had a lower incidence of anastomotic leakage and stricture. TS should be preferentially recommended. Large-scale RCTs will be needed to provide more evidence in future studies.