Cardiorespiratory Comorbidity and Postoperative Complications following Esophagectomy: a European Multicenter Cohort Study

Physical fitness predicts post-esophagectomy complications after chemoradiotherapy: a pilot study

BACKGROUND

Esophagectomy following neoadjuvant chemoradiotherapy or definitive chemoradiotherapy has been shown to yield favorable oncological outcomes in patients with locally advanced esophageal squamous cell carcinoma. However, postoperative complications are frequent and can adversely affect patient survival. This study aimed to identify physical fitness factors across multiple domains associated with major postoperative complications.

METHODS

This study enrolled patients with esophageal squamous cell carcinoma who were treated with neoadjuvant chemoradiotherapy or definitive chemoradiotherapy and underwent esophagectomy between 2020 and 2022. Multivariate logistic regression analysis was conducted to identify the factors associated with major postoperative complications. Additionally, a tree-based learning process was employed to assess all the variables influencing major complications.

RESULTS

A total of 142 esophageal cancer patients who underwent esophagectomy were screened. Of these, 72 eligible patients were included in the study, and 29 (40.2%) experienced major postoperative complications. In the full model, factors such as low body weight, low body mass index, low peak oxygen consumption (V̇O2peak), low V̇O2peak/skeletal muscle mass (SMM), low appendicular skeletal muscle index (ASMI), and low ASMI-V̇O2peak/SMM product (AV̇P) were found to be significantly associated with major postoperative complications. However, in the parsimonious model, only low AV̇P (P < 0.01) was associated with major complications. Additionally, AV̇P, EqO2nadir, and hand grip strength emerged as the key predictors of major post-esophagectomy complications in the tree-based learning analysis, which showed a sensitivity of 0.448, specificity of 0.977, and accuracy of 76.4%, with false negative and false positive rates of 55.2% and 2.3%. AV̇P alone yielded similar results.

CONCLUSIONS

Patients with low AV̇P, high EqO2nadir, and low HGS are at a very high risk of experiencing major postoperative complications, with low AV̇P showing the strongest correlation. Preoperative physical fitness screening can help identify high-risk patients and guide appropriate perioperative management.

Application of modified neck drainage in the management of cervical anastomotic fistula in esophageal cancer patients

BACKGROUND

Anastomotic fistula is a rare but life-threatening complication of esophageal cancer, and its treatment remains challenging.We aimed to evaluate the clinical efficacy of modified cervical drainage in the management of cervical anastomotic fistula in patients after esophageal cancer surgery.

METHODS

From June 2017 to December 2021, 25 esophageal cancer patients who developed cervical anastomotic fistula were enrolled in the study. Among them, 14 patients were treated with modified cervical drainage, which served as the observation group, while the remaining 11 patients underwent open incision and drainage, which served as the control group. The treatment outcomes of the two groups were compared and analyzed.

RESULTS

The observation group had a significantly shorter healing time, fewer dressing changes, shorter hospital stay, and lower hospitalization costs compared to the control group (P < 0.05). The incidence of complications in the neck was not significantly different between the two groups (P > 0.05). All patients resumed a normal diet without experiencing fever, coughing or other discomfort, and were discharged after a smooth recovery.

CONCLUSIONS

Modified neck drainage, as a treatment method for cervical anastomotic leakage in esophageal cancer patients, has preliminarily demonstrated potential in promoting patient recovery. However, its efficacy still requires further validation and confirmation through studies with larger sample sizes.

Anastomotic Leak After Esophagectomy: Analysis of the STS General Thoracic Surgery Database

BACKGROUND

Anastomotic leak after esophagectomy is a major cause of morbidity and mortality. We sought to identify the prevalence of anastomotic leak, stratified by operative approach and disease etiology, as well as risk factors for leak.

METHODS

A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted on patients who underwent esophagectomy with gastric reconstruction between 2009 and 2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop an anastomotic leak. Multivariable mixed effects logistic regression models identified risk factors for leak.

RESULTS

Of 18,419 patients, 3416 (19%) developed an anastomotic leak. Patients who leaked had more comorbidities, including obesity and diabetes. There was no difference in leak based on disease etiology (P = .435.) Patients with anastomotic leak had increased 30-day mortality (7% vs 4%, P < .001), reoperation (58% vs 10%, P < .001), and longer lengths of stay (18 vs 10 days, P < .001). On multivariable analysis, obesity (odds ratio [OR], 1.27; 95% CI, 1.16-1.38; P < .001), diabetes (OR, 1.14; 95% CI, 1.04-1.25; P = .006), and smoking (OR, 1.26; 95% CI, 1.15-1.37; P < .001) were independently predictive of anastomotic leak. Compared with an open 2-field, a transhiatal (OR, 1.35; 95% CI, 1.17-1.55; P < .001) or 3-field esophagectomy (OR, 1.46; 95% CI, 1.25-1.70; P < .001) was more likely to leak. A robotic approach was associated with an increased risk of leak (OR, 1.28; 95% CI, 1.03-1.08; P < .001), however lost significance in a modern subgroup from 2018-2021.

CONCLUSIONS

Obesity, diabetes, smoking, pulmonary hypertension, and a cervical anastomosis are risk factors for anastomotic leak regardless of disease etiology. These important clinical risk factors identify an opportunity for modifiable risk reduction with aggressive medical optimization perioperatively.

[Multimorbid patients in visceral surgery-Upper gastrointestinal tract]

The treatment of multimorbid patients in oncological surgery of the upper gastrointestinal tract requires a differentiated consideration of every single risk factor in order to provide a holistic assessment. This article focuses on pre-existing diseases that are particularly relevant for elective esophageal and gastric surgery and have practical clinical consequences. In this way a differtiation is made between metabolic, vascular, cardiopulmonary and organ-specific risks. The aim of this work is to provide practical guidelines for complex and multimorbid cases. Given the multifactorial interrelationships, the importance of a thorough preoperative evaluation and interdisciplinary management cannot be overemphasized.

The anastomotic leak triad: preoperative patient characteristics, intraoperative risk factors, and postoperative outcomes

BACKGROUND

The aim of this study was to determine perioperative risk factors associated with anastomotic leak (AL) after minimally invasive esophagectomy (MIE) and its association with cancer recurrence and overall survival.

METHODS

This retrospective observational study of electronic health record data included patients who underwent MIE for esophageal cancer between September 2013 and July 2023 at a tertiary center. The primary outcome was AL after esophagectomy, whereas the secondary outcomes included time to cancer recurrence and overall survival. Perioperative patient factors were evaluated to determine their associations with the primary and the secondary outcomes. Propensity score-matched logistic regression assessed the associations between perioperative factors and AL. Kaplan-Meier survival curves compared cancer recurrence and overall survival by AL.

RESULTS

A total of 251 consecutive patients with esophageal cancer were included in the analysis; 15 (6%) developed AL. Anemia, hospital complications, hospital length of stay, and 30-day readmissions significantly differed from those with and without AL (P = .037, <.001, <.001, and.016, respectively). Moreover, 30- and 90-day mortality were not statistically affected by the presence of AL (P = .417 and 0.456, respectively). Logistic regression modeling showed drug history and anemia were significantly associated with AL (P = .022 and.011, respectively). The presence of AL did not significantly impact cancer recurrence or overall survival (P = .439 and.301, respectively).

CONCLUSION

The etiology of AL is multifactorial. Moreover, AL is significantly associated with drug history, preoperative anemia, hospital length of stay, and 30-day readmissions, but it was not significantly associated with 30- or 90-day mortality, cancer recurrence, or overall survival. Patients should be optimized before undergoing MIE with special consideration for correcting anemia. Ongoing research is needed to identify more modifiable risk factors to minimize AL development and its associated morbidity.

Effect of Volatile Anesthesia Versus Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Minimally Invasive Esophagectomy: A Randomized Clinical Trial

BACKGROUND

The effect of intraoperative anesthetic regimen on pulmonary outcome after minimally invasive esophagectomy for esophageal cancer is yet undetermined. The aim of this study was to determine the effect of volatile anesthesia (sevoflurane or desflurane) compared with propofol-based intravenous anesthesia on pulmonary complications after minimally invasive esophagectomy.

METHODS

Patients scheduled for minimally invasive esophagectomy were randomly assigned to 1 of 3 general anesthetic regimens (sevoflurane, desflurane, or propofol). The primary outcome was the incidence of pulmonary complications within the 7 days postoperatively, which was a collapsed composite end point, including respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm, pulmonary embolism, and aspiration pneumonitis. The severity of pulmonary complications, surgery-related complications, and other secondary outcomes were also assessed.

RESULTS

Of 647 patients assessed for eligibility, 558 were randomized, and 553 were analyzed. A total of 185 patients were assigned to the sevoflurane group, 185 in the desflurane, and 183 in the propofol group. Patients receiving a volatile anesthetic (sevoflurane or desflurane) had a significantly lower incidence (36.5% vs 47.5%; odds ratio, 0.63; 95% confidence interval, 0.44-0.91; P = .013) and lower severity grade of pulmonary complications ( P = .035) compared to the patients receiving propofol. There were no statistically significant differences in other secondary outcomes between the 2 groups.

CONCLUSIONS

In patients undergoing minimally invasive esophagectomy, the use of volatile anesthesia (sevoflurane or desflurane) resulted in the reduced risk and severity of pulmonary complications within the first 7 postoperative days as compared to propofol-based intravenous anesthesia.

Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center

Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.

Nomograms to predict tumor regression grade (TRG) and ypTNM staging in patients with locally advanced esophageal cancer receiving neoadjuvant therapy

BACKGROUND

Neoadjuvant therapy (NT) has increased survival rates for patients with locally advanced esophageal cancer (EC), but estimating the impact of NT treatment prior to surgery is still very difficult.

METHODS

A retrospective study of the clinical information of 150 patients with locally advanced EC who got NT at Qilu Hospital of Shandong University between June 2018 and June 2023. Patients were randomized into training and internal validation groups at a 3:1 ratio. Furthermore, an external validation cohort comprised 38 patients who underwent neoadjuvant therapy at Qianfoshan Hospital in the Shandong Province between June 2021 and June 2023. Independent risk factors were identified using univariate and multivariate logistic regression (forward stepwise regression). Predictive models and dynamic web nomograms were developed by integrating these risk factors.

RESULTS

A total of 188 patients with locally advanced EC were enrolled, of whom 118 achieved stage I of neoadjuvant pathologic TNM (ypTNM) after receiving NT and 129 achieved grades 0-1 in the tumor regression grade (TRG). Logistic regression analysis identified five independent predictors of TRG grades 0-1: pulmonary function tests (PFT), prognostic nutritional index (PNI), triglyceride (TG) levels, squamous cell carcinoma antigen (SCC-Ag) levels, and combination immunotherapy. The areas under the receiver operating characteristic (ROC) curves for the training, internal validation, and external validation groups were 0.87, 0.75, and 0.80, respectively. Meanwhile, two independent predictors of stage I of ypTNM were identified: prealbumin (PA) and SCC antigen. The areas under the ROC curves for the training, internal validation, and external validation groups were 0.78, 0.67, and 0.70, respectively. The Hosmer-Lemeshow test for both predictive models showed excellent calibration, with well-fitted calibration curves. Decision curve analysis (DCA) and clinical impact curves (CIC) have demonstrated that nomograms are of clinical utility.

CONCLUSION

The nomograms performed well in predicting the likelihood of stage I of ypTNM and TRG grade 0-1 after NT in patients with locally advanced EC. It helps thoracic surgeons to predict the sensitivity of patients to NT before surgery, which enables precise treatment of patients with locally advanced EC.

Multi-disciplinary management of esophageal carcinoma: Current practices and future directions

Esophageal cancer in one of the most malignant and hard-to-treat cancers. Esophageal squamous carcinoma (ESCC) is most common in Asian countries, whereas adenocarcinoma at the esophago-gastric junction (EGJ AC) is more prevalent in the Western countries. Due to differences in both genetic background and response to chemotherapy and radiotherapy, both histologic subtypes need different paradigms of management. Since the landmark CROSS study has demonstrated the superior survival benefit of tri-modality including neoadjuvant chemoradiotherapy prior to esophagectomy, the tri-modality becomes the standard of care; however, it is suitable for a highly-selected patient. Tri-modality should be offered for every ESCC patient, if a patient is fit for surgery with adequate cardiopulmonary reserve, regardless of ages. Definitive chemoradiotherapy remains the best option for a patient who is not a surgical candidate or declines surgery. On the contrary, owing to doubtful benefits of radiotherapy with potentially more toxicities related to radiotherapy in EGJ AC, either neoadjuvant chemotherapy or peri-operative chemotherapy would be more preferable in an EGJ AC patient. In case of very locally advanced disease (cT4b), the proper management is more challenging. Even though, palliative care is the safe option, multi-modality therapy with curative intent like neoadjuvant chemotherapy with conversion surgery may be worthwhile; however, it should be suggested on case-by-case basis.

Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer

Esophagectomy is an exemplar of complex oncological surgery and is associated with a relatively high risk of major morbidity and mortality. In the modern era, where specific complications are targeted in prevention and treatment pathways, and where the principles of enhanced recovery after surgery are espoused, optimum outcomes are targeted via a number of approaches. These include comprehensive clinical and physiological risk assessment, specialist perioperative care by a high-volume team, and multimodal inputs throughout the patient journey that aim to preserve or restore nutritional deficits, muscle mass and function.

Relationship between the severity of emphysematous change in the lung and morbidity after esophagectomy for esophageal cancer: A retrospective study on a novel strategy for risk prediction

BACKGROUND

Chronic obstructive pulmonary disease (COPD) prevalence increases post-esophagectomy morbidity. However, the association between COPD severity and post-esophagectomy morbidity remains unclear because of the lack of an objective method to classify COPD severity. Low attenuation volume ratio (LAVR) estimated using Ziostation2 may reflect the extent of emphysematous changes in the lungs and COPD severity, thereby predicting post-esophagectomy morbidity.

METHODS

A total of 776 patients who underwent curative McKeown esophagectomy for esophageal cancer between April 2005 and June 2021 were included. The patients were divided into high and low preoperative LAVR groups. Short-term outcomes between the groups were compared for patients who underwent open esophagectomy (OE) and minimally invasive esophagectomy (MIE).

RESULTS

A total of 219 (28%) patients were classified into the high LAVR group. High LAVR was significantly associated with disadvantageous patient characteristics such as advanced age, heavy smoking, and impaired respiratory function. Patients with high LAVR had a significantly higher incidence of severe morbidity and pneumonia after OE. High LAVR was an independent risk factor for severe morbidity (odds ratio [OR], 2.52; 95% confidence interval [CI]: 1.237-5.143; p = 0.011) and pneumonia (OR, 2.12; 95% CI: 1.003-4.493; p = 0.049) after OE. Meanwhile, LAVR was not correlated with the incidence of post-MIE morbidity.

CONCLUSIONS

LAVR may reflect COPD severity and predict severe morbidity and pneumonia after OE, but not after MIE. Less invasiveness of MIE may alleviate the effects of various disadvantageous backgrounds associated with high LAVR on worse short-term outcomes.

Effect of Neoadjuvant Immunotherapy Combined with Chemotherapy on Pulmonary Function and Postoperative Pulmonary Complications in Esophageal Cancer: A Retrospective Study

BACKGROUND

Neoadjuvant immunotherapy, targeting the PD-1 or PD-L1, combined with chemotherapy (NICT), can improve the radical resection and survival rates for locally advanced EC. However, it may impair pulmonary function, and the effect of NICT on pulmonary function and postoperative pulmonary complications in EC patients remains unknown. This study aimed to investigate whether NICT can affect pulmonary functions and postoperative pulmonary complications in EC patients.

METHODS

The study retrospectively recruited 220 EC patients who received NICT at the Department of Esophageal Cancer in Tianjin Medical University Cancer Institute & Hospital from January 2021 to June 2022. Changes in pulmonary function before and after NICT were compared. Logistic regression analysis was performed to analyze the correlations of pulmonary functions and clinical characteristics with postoperative pulmonary complications, respectively.

RESULTS

The FEV1% pred, FVC, FVC% pred, and FEV1/FVC% significantly increased after NICT, with a P-value of 0.018, 0.005, 0.001, and 0.036, respectively. In contrast, there was a significant decline in the DLCO (8.92 ± 2.34 L before NICT vs. 7.79 ± 2.30 L after NICT; P < 0.05) and DLCO% pred (102.97 ± 26.22% before NICT vs. 90.18 ± 25.04% after NICT; P < 0.05). High DLCO and DLCO% pred at baseline levels were risk factors for DLCO reduction in EC patients after NICT. Advanced age, smoking history, FEV1% pred after NICT, and FVC% pred baseline and after therapy were risk factors for postoperative pulmonary complications, with a P-value of 0.043, 0.038, 0.048, 0.034, and 0.004, respectively. Although the DLCO level decreased after NICT, it did not increase the incidence of postoperative pulmonary complications.

CONCLUSION

NICT may improve pulmonary ventilation function but also lead to a decrease in DLCO and DLCO% pred in EC patients. Nevertheless, the decreased DLCO after NICT did not increase the risk of postoperative pulmonary complications.

Mechanical properties and tissue damage caused by staples in gastrointestinal anastomosis

Gastrointestinal surgery using a stapler is usually associated with tissue damage, anastomosis leakage, bleeding, and other complications, which is one of the effective methods for treating digestive tract cancer. The cutting properties of staples and the tissue damage occurring in the process of stapling porcine esophageal and gastric tissues have been evaluated and a new type of stapler has been designed. Since different structural and mechanical properties esophageal and gastric tissues layers, the puncturing force exhibits a fluctuating trend. Compressive stress caused by the bending of the staple legs can lead to the destruction of the vascular network inside the tissue, tissue deforms and tears. Finally, a staple with an internal incision arc (IIA) tip is designed, which meeting the performance requirements.

Effects of neoadjuvant therapy on health-related quality of life for patients with gastroesophageal cancer

BACKGROUND

Neoadjuvant therapy in combination with surgery increases survival in gastroesophageal cancer; however, little is known about its impact on health-related quality of life. This study compared the impact of neoadjuvant therapy with that of surgery alone on the health-related quality of life in patients treated for gastroesophageal cancer.

METHODS

A single-centre cohort study with prospectively collected data from patients undergoing curative intended treatment for gastroesophageal cancer between 2013 and 2020 was performed. Health-related quality of life was assessed prior to surgery and patients stratified according to neoadjuvant therapy or surgery alone. The primary endpoint was self-assessed health-related quality of life, evaluated using validated cancer-specific questionnaires. A pre-specified multivariable model adjusted for age, ASA score, and clinical T- and N-stage was used.

RESULTS

A total of 361 patients were included, of whom 239 (61%) were treated with neoadjuvant therapy. Patients treated with neoadjuvant therapy reported less difficulties with eating restrictions (-11.9, p = 0.005), pain (-10.9, p = 0.004), and insomnia (-12.6, p = 0.004) than patients treated with surgery alone. Patients with oesophageal cancer and neoadjuvant therapy reported less dysphagia (-16.6, p < 0.001), eating restrictions (-23.2, p < 0.001), and odynophagia (-18.0, p = 0.002) than those who underwent surgery alone.

CONCLUSION

Neoadjuvant therapy was associated with a significant reduction in symptoms affecting malnutrition and improved health-related quality of life in patients with gastroesophageal cancer. These results indicates that more patients might be available for neoadjuvant therapy, despite the baseline burden of gastroesophageal cancer.

Does Neoadjuvant Radiation Therapy Contribute to the Incidence of Pulmonary Complications Following Esophagectomy for Malignant Neoplasm?

BACKGROUND

Post-operative pulmonary complications (POPC) are common in patients undergoing esophagectomy and neoadjuvant radiotherapy may exacerbate POPC. This study assessed whether neoadjuvant radiation increases the incidence of POPC in patients undergoing esophagectomy for malignancy.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program database files from 2016 to 2018 were queried for patients undergoing esophagectomy for malignancy. Inverse probability treatment weighting (IPTW) was used to create balanced cohorts in which the control group received neoadjuvant chemotherapy (nCT) and the treatment cohort received neoadjuvant chemoradiotherapy (nCRT). A subset analysis was performed on patients with pre-existing pulmonary disease (PEPD). Primary outcomes were POPC and 30-day mortality.

RESULTS

The all-patient analysis did not demonstrate a consistent association between neoadjuvant radiation and POPC. However, in patients with PEPD, POPC occurred more often in the nCRT cohort. Comparing nCRT to nCT and after IPTW adjustment for confounders, there was higher odds of pneumonia (aOR = 3.0, P = .002), unplanned intubation (aOR = 2.0, P = .03), and extended mechanical ventilation (aOR = 3.6, P = .002).

DISCUSSION

In esophageal cancer patients with PEPD that undergo nCRT vs nCT prior to esophagectomy, the greater risk of POPCs must be weighed against the potential for improved oncologic outcomes.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer

BACKGROUND

This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate.

METHODS

We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT).

RESULTS

POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35 mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35 mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01).

CONCLUSION

Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Surgical outcomes of 500 robot-assisted minimally invasive esophagectomies for esophageal carcinoma

Background

In 2003, robot-assisted minimally invasive esophagectomy (RAMIE) was first reported to overcome the technical limitations of minimally invasive esophagectomy. RAMIE requires repeated modifications to set up the robotic system, and sufficient experience is required to gain technical proficiency. This study aimed to identify the learning periods and the outcomes of RAMIE for esophageal carcinoma.

Methods

We retrospectively reviewed 500 consecutive RAMIE cases for esophageal cancer from December 2008 to February 2021. The learning curve for RAMIE was identified using cumulative sum analysis.

Results

In a total of 500 RAMIE patients, the Ivor Lewis and McKeown operation were performed in 267 patients (53.4%) and 192 patients (38.4%), respectively. We classified learning periods into the learning phase (first 50 cases), the developing phase (51-150 case), and the stable phase (151-500 case). The rates of vocal cord palsy (42.0% vs. 28.4%) and anastomotic leakage (10.0% vs. 6.4%) were reduced after the learning phase. The mean total operative time (420 vs. 373 min), the mean length of stay (21.6 vs. 16.7 days), and the rate of anastomotic stricture (27.0% vs. 12.4%) were significantly reduced after reaching stable phase. In the stable phase, the proportion of the Ivor Lewis operation (26.0% vs. 67.1%), neoadjuvant chemoradiation therapy (14.0% vs. 25.7%), and bilateral cervical node dissection cases (12.0% vs. 22.0%) were significantly increased.

Conclusions

Fifty procedures might be needed to achieve early proficiency, and extensive experience of more than 150 procedures is needed for quality stabilization.

Integration of functional capacity to medically necessary, time-sensitive scoring system: A prospective observational study

OBJECTIVES

To evaluate 2 new modifications to medically necessary, time-sensitive (MeNTS) scoring systems integrating functional capacity assessment in estimating intensive care unit (ICU) requirements.

METHODS

This prospective observational study included patients undergoing elective surgeries between July 2021 and January 2022. The MeNTS scores and our 2 modified scores: MeNTS-METs (integrated Duke activity status index [DASI] as metabolic equivalents [METs]) and MeNTS-DASI-5Q (integrated modified DASI [M-DASI] as 5 questions) were calculated. The patients' ICU requirements (group ICU+ and group ICU-), DASIs, patient-surgery-anesthesia characteristics, hospital stay lengths, rehospitalizations, postoperative complications, and mortality were recorded.

RESULTS

This study analyzed 718 patients. The MeNTS, MeNTS-METs, and MeNTS-DASI-5Q scores were higher in group ICU+ than in group ICU- (p<0.001). Group ICU+ had longer operation durations and hospital stay lengths (p<0.001), lower DASI scores (p<0.001), and greater hospital readmissions, postoperative complications, and mortality (p<0.001). The MeNTS-METs and MeNTS-DASI-5Q scores better predicted ICU requirement with areas under the receiver operating characteristic curve (AUC) of 0.806 and 0.804, than the original MeNTS (AUC=0.782).

CONCLUSION

The 5-questionnaire M-DASI is easy to calculate and, when added to a triage score, is as reliable as the original DASI for predicting postoperative ICU requirements.

Evolution of a minimally invasive oesophagectomy program - effective complication management is key

Introduction

Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures.

Aim

To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management.

Material and methods

All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery).

Results

In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort.

Conclusions

Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.

Combined and intraoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND

Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions.

AIM

To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness.

RESULTS

Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness.

CONCLUSION

Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Effect of initiative pulmonary bullectomy on the risk of post-operative pneumothorax in patients with esophageal carcinoma: a propensity score-matched analysis

Background

Postoperative pneumothorax can lead to additional invasive intervention and extended hospitalization. The effect of initiative pulmonary bullectomy (IPB) during the esophagectomy on preventing postoperative pneumothorax remains controversial. This study evaluated the efficacy and safety of IPB in patients who underwent minimally invasive esophagectomy (MIE) for esophageal carcinoma complicated by ipsilateral pulmonary bullae.

Methods

Data from 654 consecutive patients with esophageal carcinoma who underwent MIE from January 2013 to May 2020 were retrospectively collected. A total of 109 patients who had a definite diagnosis of ipsilateral pulmonary bullae were recruited and classified into two groups: the IPB group and the control group (CG). Propensity score matching (PSM, match ratio =1:1), incorporating preoperative clinical features, was used to compare the perioperative complications and analyze efficacy and safety between IPB and control group.

Results

The incidences of postoperative pneumothorax in the IPB and control groups was 3.13% and 40.63% respectively, with a significant difference (P<0.001). Logistic analyses indicated that removing ipsilateral bullae was associated with a lower risk (OR 0.030; 95% CI: 0.003-0.338; P=0.005) of incident postoperative pneumothorax. No significant difference was found between the two groups in terms of the incidence of anastomotic leakage (6.25% vs. 3.13%, P=1.000), arrhythmia (3.13% vs. 3.13%, P=1.000), chylothorax (0% vs. 3.13%, P=1.000) and other common complications.

Conclusions

In esophageal cancer patients with ipsilateral pulmonary bullae, IPB performed in the same anesthesia process is an effective and safe method for the prevention of postoperative pneumothorax, allowing for a shorter postoperative rehabilitation time, and it does not exert unfavorable effects on complications.

An Association Between Comorbidities and Postsurgical Complications in Adults Who Underwent Esophagectomy

Background Esophagectomy is the surgical excision of part or all of the esophagus and is associated with both common and serious complications. Various comorbidities, such as diabetes mellitus, smoking, and congestive heart failure (CHF), have been detected in individuals who have undergone esophagectomy. This study investigates the association of baseline characteristics and comorbidities with postoperative complications. Methods A retrospective cohort study based on data from the National Surgical Quality Improvement Program database was conducted, evaluating 2,544 patients who underwent esophagectomy between January 2016 and December 2018. Data included baseline characteristics, established comorbidities, and postoperative complications within 30 days of the procedure. Risk-adjusted and unadjusted logistic regressions were used to assess the odds of postoperative complications against baseline characteristics. Results The majority of our population were white males (80.8% male; 78.2% white), with a mean age of 63.5 years. More than half of the patients were overweight or obese. A minority of our patients had a smoking history, weight loss, diabetes mellitus, chronic obstructive pulmonary disease (COPD), or CHF. The most frequent postoperative complications were as follows: return to the operating room (15.7%), anastomotic leak (12.9%), pneumonia (12.7%), bleeding/transfusions (11.8%), readmissions (11.4%), and unplanned intubation (10.5%). Adjusted associations for odds of experiencing a postoperative complication were found to be statistically significant for age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, and P < 0.001), operation time (OR 1.002, 95% CI 1.001-1.003, and P < 0.001), race (not white) (OR 1.76, 95% CI 1.26-2.47, and P = 0.001), BMI (underweight) (OR 2.18, 95% CI 1.36-3.50, and P = 0.001), smoking (OR 1.42, 95% CI 1.14-1.76, and P = 0.001), and chemotherapy and/or radiation (OR 0.82, 95% CI 0.68-0.99, P = 0.038). Conclusions Our study found that age, operation time, nonwhite race, underweight BMI, and smoking were independently associated with an increased risk of developing a postoperative complication following esophagectomy. Additionally, neoadjuvant chemotherapy and/or radiation are associated with a decreased risk. Understanding how baseline characteristics and comorbidities can affect rates of postoperative complications may help to adjust care for patients in both pre- and postoperative settings.

Concomitant preoperative airflow obstruction confers worse prognosis after trans-thoracic surgery for esophageal cancer

Background

Airflow obstruction is a critical element of chronic airway diseases. This study aimed to evaluate the impact of preoperative airflow obstruction on the prognosis of patients following surgery for esophageal carcinoma.

Methods

A total of 821 esophageal cancer patients were included and classified into two groups based on whether or not they had preoperative airflow obstruction. Airflow obstruction was defined as a forced expiration volume in the first second (FEV₁)/forced vital capacity (FVC) ratio below the lower limit of normal (LLN). A retrospective analysis of the impact of airflow obstruction on the survival of patients with esophageal carcinoma undergoing esophagectomy was performed.

Results

Patients with airflow obstruction (102/821, 12.4%) had lower three-year overall (42/102, 58.8%) and progression-free survival rate (47/102, 53.9%) than those without airflow obstruction (P < 0.001). Multivariate analyses showed that airflow obstruction was an independent risk factor for overall survival (Hazard Ratio = 1.66; 95% CI: 1.17-2.35, P = 0.004) and disease progression (Hazard Ratio = 1.51; 95% CI: 1.1-2.08; P = 0.01). A subgroup analysis revealed that the above results were more significant in male patients, BMI < 23 kg/m² patients or late-stage cancer (stage III-IVA) (P = 0.001) patients and those undergoing open esophagectomy (P < 0.001).

Conclusion

Preoperative airflow obstruction defined by FEV₁/FVC ratio below LLN was an independent risk factor for mortality in esophageal cancer patients after trans-thoracic esophagectomy. Comprehensive management of airflow obstruction and more personalized surgical decision-making are necessary to improve survival outcomes in esophageal cancer patients.

Risk model for mortality associated with esophagectomy via a thoracic approach based on data from the Japanese National Clinical Database on malignant esophageal tumors

PURPOSE

Postoperative complications after esophagectomy can be severe or fatal and impact the patient's postoperative quality of life and long-term outcomes. The aim of the present study was to develop the best possible model for predicting mortality and complications based on the Japanese Nationwide Clinical Database (NCD).

METHODS

Data registered in the NCD, on 32,779 patients who underwent esophagectomy via a thoracic approach for malignant esophageal tumor between January, 2012 and December, 2017, were used to create a risk model.

RESULTS

The 30-day mortality rate after esophagectomy was 1.0%, and the operative mortality rate was 2.3%. Postoperative complications included pneumonia (13.8%), anastomotic leakage (13.2%), recurrent laryngeal nerve palsy (11.1%), atelectasis (4.9%), and chylothorax (2.5%). Postoperative artificial respiration for over 48 h was required by 7.8% of the patients. Unplanned intubation within 30 postoperative days was performed in 6.2% of the patients. C-indices evaluated using the test data were 0.694 for 30-day mortality and 0.712 for operative mortality.

CONCLUSIONS

We developed a good risk model for predicting 30-day mortality and operative mortality after esophagectomy based on the NCD. This risk model will be useful for the preoperative prediction of 30-day mortality and operative mortality, obtaining informed consent, and deciding on the optimal surgical procedure for patients with preoperative risks for mortality.

Risk Factors for Chronic Atrial Fibrillation Development After Esophagectomy for Esophageal Cancer

BACKGROUND

This study investigates the prognosis of patients with postoperative atrial fibrillation (POAF), aiming to elucidate predictors of occurrence of atrial fibrillation (AF) in the chronic phase after esophagectomy.

METHODS

We retrospectively analyzed 415 consecutive patients between July 2010 and December 2021 who were scheduled to undergo esophagectomy for esophageal cancer and had no previous history of AF.

RESULTS

POAF occurred in 73 patients (18%). Their ages were higher than those without POAF (72 [66-77] vs 68 [62-75], P < 0.01). Three-field lymph node dissection was more frequent in patients with POAF (63% vs 50%, P = 0.04). Overall survival rates were not significantly different between those with and without POAF in patients with stage III/IV cancer (P = 0.37), but overall survival rate of patients with POAF was lower than in those without POAF in stage I/II cancer (P = 0.03). Seventeen patients (4.1%) had recurrence of AF or new onset 31 days after esophagectomy. POAF was the only independent predictor of AF development in the chronic phase (HR: 4.09, 95%CI: [1.42-11.74], P = 0.01). AF development in the chronic phase was observed in 8 patients (11.0%) with and 9 patients (2.6%) without POAF (P < 0.01). AF development rates were not significantly different in patients with stage III/IV cancer (P = 0.05), but there was significant difference in patients with stage I/II cancer (P < 0.01).

CONCLUSION

The occurrence of POAF after esophagectomy is related with future development of AF and overall survival prognosis. Future studies must ascertain optimal therapeutic strategy.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion

Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.

Preoperative Smoking Cessation and Prognosis After Curative Esophagectomy for Esophageal Cancer: A Cross-Sectional Study

BACKGROUND

Several cohort studies have reported that post-esophagectomy morbidities may worsen prognosis. Smoking cessation is an effective prophylactic measure for reducing post-esophagectomy morbidity; however, whether smoking cessation can contribute to the improvement of prognosis is unknown due to the absence of reliable databases covering the cessation period. This study aimed to elucidate whether sufficient preoperative smoking cessation can improve prognosis after esophageal cancer surgery by reducing post-esophagectomy morbidity.

METHODS

This study included 544 consecutive patients who underwent curative McKeown and Ivor-Lewis esophagectomies for esophageal cancer between May 2011 and June 2021. Data on smoking status and cessation period were prospectively accumulated. Survival data were finally updated on 30 January 2022. Receiver operating characteristic curve analysis for the cut-off value of appropriate cessation period in reducing post-esophagectomy respiratory morbidity as well as analyses for the association of cessation period with short- and long-term outcomes were performed.

RESULTS

Post-esophagectomy morbidity significantly diminished overall survival (OS) after esophagectomy (p = 0.0003). A short preoperative smoking cessation period of ≤ 2 months was associated with frequent post-esophagectomy morbidity of Clavien-Dindo classification ≥IIIb (p = 0.0059), pneumonia (p = 0.016), respiratory morbidity (p = 0.0057), and poor OS in clinical stages II and III (p = 0.0015). Moreover, it was an independent factor for poor OS (hazard ratio 1.85, 95% confidence interval 1.068-3.197; p = 0.028), along with body mass index <18.5 and R1 resection.

CONCLUSIONS

Sufficient preoperative smoking cessation > 2 months may be effective in improving not only short-term outcomes but also prognosis after esophagectomy for locally advanced esophageal cancer.

Neoadjuvant Immune Checkpoint Inhibitors Plus Chemotherapy in Locally Advanced Esophageal Squamous Cell Carcinoma: Perioperative and Survival Outcomes

Background

Immune checkpoint inhibitors (ICI) improve survival in patients with late-stage esophageal squamous cell carcinoma (ESCC) but have not been fully evaluated in locally advanced ESCC.

Method

We retrospectively assessed outcomes of consecutive, treatment-naïve locally advanced ESCC (stage III or IVA) adults treated with neoadjuvant ICI plus chemotherapy followed by surgery, who refused or lacked access to radiotherapy, with regards to surgery feasibility, pathological response, and relapse-free survival (RFS).

Results

We uneventfully treated 34 patients with the combined regimen in 2020. None reported grade III or higher toxic effects. All underwent surgery as planned: 32 received complete (R0) resections and 2 had microscopically positive margins (R1). Tumor downstaging occurred in 33 (97.1%) patients and 11 (32.4%) had pathologically complete response of the primary lesion. Median postoperative length of stay was 12 days (interquartile range: 11 to 17). All patients resumed a semi-liquid diet on discharge. The 90-day postoperative morbidity rate was 20.6% (7/34) with no mortalities. The 1-year RFS was 77.8% [95% CI, 64.2-94.2].

Conclusion

Neoadjuvant ICI plus chemotherapy was safe and resulted in significant downstaging, rendering inoperable tumors operable, relieving symptoms of dysphagia and prolonging survival for locally advanced ESCC patients who refused or lacked access to radiotherapy.

Difference between “Lung Age” and Real Age as a Novel Predictor of Postoperative Complications, Long-Term Survival for Patients with Esophageal Cancer after Minimally Invasive Esophagectomy

Background

This study aimed to investigate whether the difference between “lung age” and real age (L–R) could be useful for the prediction of postoperative complications and long-term survival in patients with esophageal cancer followed by minimally invasive esophagectomy (MIE).

Methods

This retrospective cohort study included 625 consecutive patients who had undergone MIE. “Lung age” was determined by the calculation method proposed by the Japanese Respiratory Society. According to L–R, patients were classified into three groups: group A: L–R ≦ 0 (n = 104), group B: 15 > L–R > 0 (n = 199), group C: L–R ≥ 15 (n = 322). Clinicopathological factors, postoperative complications evaluated by comprehensive complications index (CCI), and overall survival were compared between the groups. A CCI value >30 indicated a severe postoperative complication.

Results

Male, smoking status, smoking index, chronic obstructive pulmonary disease, American Society of Anesthesiologists status, lung age, and forced expiratory volume in 1 s were associated with group classification. CCI values, postoperative hospital stays, and hospital costs were significantly different among groups. Multivariate analysis indicated that L–R, coronary heart disease, and 3-field lymphadenectomy were significant factors for predicting CCI value >30. Regarding the prediction of CCI value >30, area under the curve value was 0.61(95%: 0.56–0.67), 0.46 (95% CI, 0.40–0.54), and 0.46 (95% CI, 0.40–0.54) for L–R, Fev1, and Fev1%, respectively. Regarding overall survival, there was a significant difference between group A and group B + C (log-rank test: p = 0.03).

Conclusions

Esophageal cancer patients with impaired pulmonary function had a higher risk of severe postoperative complications and poorer prognosis than those with normal pulmonary function. The difference between “lung age” and “real age” seems to be a novel and potential predictor of severe postoperative complications and long-term survival.

Comparison of Two Circular-Stapled Techniques for Esophageal Cancer: A Propensity-Matched Analysis

OBJECTIVE

The optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil™) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil™) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE).

METHODS

The data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage.

RESULTS

In the propensity score-matched analysis, compared with the non-Orvil™ group, the Orvil™ group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p< 0.05).

CONCLUSIONS

Orvil™ anastomosis exhibited better perioperative effects than non-Orvil™ anastomosis after the propensity score-matched analysis. Remarkably, the Orvil™ technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil™ technique.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

Reoperative Surgery After Minimally Invasive Ivor Lewis Esophagectomy

OBJECTIVE

The aim of this study is to identify factors influencing reoperations following minimally invasive Ivor Lewis esophagectomy and associated mortality and hospital costs.

MATERIALS AND METHODS

Between 2013 and 2018, 125 patients were retrospectively analyzed. Outcomes included reoperations, mortality, and hospital costs. Multivariable logistic regression analyses determined factors associated with reoperations.

RESULTS

In-hospital reoperations (n=10) were associated with in-hospital mortality (n=3, P<0.01), higher hospital costs (P<0.01), and longer hospital stay (P<0.01). Conversely, reoperations after discharge were not associated with mortality. By multivariable analysis, baseline cardiovascular (P=0.02) and chronic kidney disease (P=0.01) were associated with reoperations. However, anastomotic leaks were not associated with reoperations nor mortality.

CONCLUSION

The majority of reoperations occur within 30 days often during index hospitalization. Reoperations were associated with increased in-hospital mortality and hospital costs. Notably, anastomotic leaks did not influence reoperations nor mortality. Efforts to optimize patient baseline comorbidities should be emphasized to minimize reoperations following minimally invasive Ivor Lewis esophagectomy.

Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses

OBJECTIVE

The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy.

BACKGROUND

Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%.

METHODS

We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer.

RESULTS

Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m² were associated with increased risk for mortality.

CONCLUSIONS

Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.

Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer

BACKGROUND

Identifying predictors of anastomotic leakage can contribute to prevention of this common complication after esophagectomy. This study identified predictors for anastomotic leakage and assessed the influence of anastomotic leakage on short-term outcomes and long-term survival.

METHODS

A retrospective cohort study was conducted of consecutive patients who underwent esophagectomy in the Amsterdam University Medical Centers, location Amsterdam Medical Center, between 1993 and 2019. Multilevel logistic and Cox regression models were used to assess predictors for anastomotic leakage and survival, and an operation year-level random effects was considered for the unmeasured characteristics at year of operation.

RESULTS

Included were 1539 patients, and anastomotic leakage developed in 288 (19%). Predictors for developing anastomotic leakage after a transthoracic esophagectomy were a higher body mass index and a cervical anastomosis. Diabetes mellitus type 2 and chronic obstructive pulmonary disease were predictors for anastomotic leakage after a transhiatal esophagectomy. Median intensive care unit and hospital stay was longer for patients with anastomotic leakage than for patients without anastomotic leakage (both P < .001 for transthoracic esophagectomy, P = .010 and P < .001, respectively, for transhiatal esophagectomy). A higher percentage of patients with anastomotic leakage died within 30 days (3.8% vs 1.9%, P = .050). However, anastomotic leakage did not significantly influence long-term survival (hazard ratio, 0.994; 95% CI, 0.849-1.176; P = .994).

CONCLUSIONS

Higher body mass index, cervical anastomosis, diabetes mellitus, and chronic obstructive pulmonary disease are predictors for anastomotic leakage after esophagectomy. Anastomotic leakage is associated with worse short-term outcomes, but long-term survival was not influenced. Future studies should focus on patient optimization, accurate patient selection, and development of tools in risk assessment.

Associations between the severity of medical and surgical complications and perception of surgeon empathy in esophageal and gastric cancer patients

OBJECTIVE

To assess the impact of global physician empathy and its three subdimensions (establishing rapport, emotional and cognitive processes) on the severity of postoperative complications in a sample of cancer patients.

METHODS

We retrospectively analyzed data on 256 patients with esogastric cancer from the French national FREGAT database. Empathy and its subdimensions were assessed using the patient-reported CARE scale and the severity of medical and surgical complications was reported with the Clavien-Dindo classification system. The usual covariates were included in multinomial logistic regression analyses.

RESULTS

Physician empathy predicted the odds of reporting major complications. When patients perceived high empathy, they were less likely to report major complications compared to no complications (OR = .95, 95% CI = [.91-.99], p = .029). Among the three dimensions, only "establishing rapport" (OR = .84, 95% CI = [.73-.98], p = .019) and the "emotional process" (OR = .85, 95% CI = [.74-.98], p = .022) predicted major complications.

CONCLUSIONS

Physician empathy is essential before surgery. Further research is needed to understand the mechanisms associating empathy with health outcomes in cancer. Physicians should be trained to establish good rapport with patients, especially in the preoperative period.

Risk of Acute Lung Injury after Esophagectomy

To develop a new approach for identifying acute lung injury (ALI) in surgical ward setting and to assess incidence rate, clinical outcomes, and risk factors for ALI cases after esophagectomy. We also compare the degree of lung injury between operative and non-operative sides. Consecutive esophageal cancer patients (n=1022) who underwent esophagectomy from Dec 2012 to Nov 2018 in our hospital were studied. An approach for identifying ALI was proposed that integrated radiographic assessment of lung edema (RALE) score to quantify degree of lung edema. Stepwise logistic regression identified risk factors for postoperative ALI incidence. The degree of bilateral lung injury was compared using the RALE score. The approach for identifying ALI in surgical ward setting was defined as acute onset, PaO₂/FiO₂≤300 mmHg, bilateral opacities on bedside chest radiograph with a RALE score≥16, and exclusion of cardiogenic pulmonary edema. Incidence rate of ALI was estimated to be 9.7%. ALI diagnosis was associated with multiple clinical complications, prolonged hospital stay, higher medical bills, and higher perioperative mortality. Nine risk factors including BMI, ASA class, DLCO%, duration of surgery, neutrophil percentage, high-density lipoprotein, and electrolyte disorders were identified. The RALE score of the lung lobes of the operative side was higher than the non-operative side. A new approach for identifying ALI in esophageal cancer patients receiving esophagectomy was proposed and several risk factors were identified. ALI is common and has severe outcomes. The lung lobes on the operative side are more likely to be affected than the non-operative side.

Burden of in-hospital care in oesophageal cancer: national population-based study

Background

Oesophageal cancer management requires extensive in-hospital care. This cohort study aimed to quantify in-hospital care for patients with oesophageal cancer in relation to intended treatment, and to analyse factors associated with risk of spending a large proportion of survival time in hospital.

Methods

All patients with oesophageal cancer in three nationwide registers over a 10-year period were included. In-hospital care during the first year after diagnosis was evaluated, and the proportion of survival time spent in hospital, stratified by intended treatment (curative, palliative or best supportive care), was calculated. Associations between relevant factors and a greater proportion of survival time in hospital were analysed by multivariable logistic regression.

Results

In-hospital care was provided for a median of 39, 26, and 15 days in the first year after diagnosis of oesophageal cancer in curative, palliative, and best supportive care groups respectively. Patients receiving curatively intended treatment spent a median of 12 per cent of their survival time in hospital during the first year after diagnosis, whereas those receiving palliative or best supportive care spent 19 and 23 per cent respectively. Factors associated with more in-hospital care included older age, female sex, being unmarried, and chronic obstructive pulmonary disease.

Conclusion

The burden of in-hospital care during the first year after diagnosis of oesophageal cancer was substantial. Important clinical and socioeconomic factors were identified that predisposed to a greater proportion of survival time spent in hospital.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer

OBJECTIVE

Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer.

METHODS

The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05).

RESULTS

We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality.

CONCLUSIONS

This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Impact of co-morbidity on reoperation or death within 90 days of surgery for oesophageal cancer

Background

The impact of preoperative co-morbidity on postoperative outcomes in patients with oesophageal cancer is uncertain. A population-based and nationwide cohort study was conducted to assess the influence of preoperative co-morbidity on the risk of reoperation or mortality within 90 days of surgery for oesophageal cancer.

Methods

This study enrolled 98 per cent of patients who had oesophageal cancer surgery between 1987 and 2015 in Sweden. Modified Poisson regression models provided risk ratios (RRs) with 95 per cent confidence intervals (c.i.) to estimate associations between co-morbidity and risk of reoperation or death within 90 days of oesophagectomy. The RRs were adjusted for age, sex, educational level, pathological tumour stage, neoadjuvant therapy, annual hospital volume, tumour histology and calendar period of surgery.

Results

Among 2576 patients, 446 (17.3 per cent) underwent reoperation or died within 90 days of oesophagectomy. Patients with a Charlson Co-morbidity Index (CCI) score of 2 or more had an increased risk of reoperation or death compared with those with a CCI score of 0 (RR 1.78, 95 per cent c.i. 1.44 to 2.20), and the risk increased on average by 27 per cent for each point increase of the CCI (RR 1.27, 1.18 to 1.37). The RR was increased in patients with pulmonary disease (RR 1.66, 1.36 to 2.04), cardiac disease (RR 1.37, 1.08 to 1.73), diabetes (RR 1.50, 1.14 to 1.99) and cerebral disease (RR 1.40, 1.06 to 1.85).

Conclusion

Co-morbidity in general, and pulmonary disease, cardiac disease, diabetes and cerebral disease in particular, increased the risk of reoperation or death within 90 days of oesophageal cancer surgery. This highlights the value of tailored patient selection, preoperative preparation and postoperative care.

Preoperative Fasting Abbreviation With Whey Protein Reduces the Occurrence of Postoperative Complications in Patients With Head and Neck Cancer: A Randomized Clinical Trial

BACKGROUND

Surgery has become the treatment of choice for head and neck cancer (HNC) in most cases. Preoperative fasting abbreviation and nutrition screening have been suggested to reduce the occurrence of postoperative complications. This study aimed to evaluate the addition of whey protein in the preoperative fasting abbreviation and to analyze the association of nutrition status on postoperative complications in patients with HNC.

METHODS

A randomized, single-blind clinical trial was performed. Patients recruited from March to November 2018 at a national cancer reference center in Brazil were divided into 2 groups: intervention group (clear fluids with carbohydrate plus whey protein [CHO-P]) and control group (clear fluids with carbohydrate only [CHO]). All patients were evaluated by the Patient-Generated Subjective Global Assessment (PG-SGA) and body mass index. Logistic regression analyses were performed to assess associations between the studied variables, generating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 49 patients met the eligibility criteria and enrolled in the study. A PG-SGA score of 4-8, indicating moderate malnutrition (OR, 10.91; 95% CI, 1.05-112.91), was an independent factor that increased the risk of postoperative complication, whereas the CHO-P group (OR, 0.04; 95% CI, 0.01-0.26) was found to be an independent factor in reducing such risk.

CONCLUSION

The addition of whey protein to clear fluids (CHO-P group) was associated with a reduced risk of postoperative complications compared with the CHO group. Furthermore, moderate malnourishment was associated with an increased risk of postoperative complications for patients with HNC.

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

BACKGROUND

Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE).

METHODS

Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications.

RESULTS

Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039-0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114-4.409, P = 0.712).

CONCLUSIONS

MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

Background

Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research.

Purpose

The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery.

Conclusions

There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.

Long-term outcome in patients operated with hybrid esophagectomy for esophageal cancer - a cohort study

Background: Over the past two decades, hybrid and total minimally invasive esophagectomy for esophageal cancer (EC) has increasingly been implemented with the aim to improve morbidity, functional result and ultimately the prognosis in these patients. However, more results are warranted and in this single-center study we report long-time outcome in a cohort of cancer patients treated with hybrid esophagectomy (HE).Material and methods: Hundred and nine patients with EC operated with HE from November 2007 to June 2013 were included. Clinical, pathological and survival data were retrieved from the patient administration system and the Norwegian Cause of Death Registry. Patients alive were asked to fill out the Ogilvie dysphagia score, EORTC QLQ-C30 and EORTC QLQ-OG25. Survival was analyzed by Kaplan-Meier's method and prognostic factors by uni- and multivariable Cox regression analyses.Results: Median overall follow-up time was 55 months (range 2-135) after R0-2 resection (n = 109) and 76 months (5-135) for R0 resection (n = 100). Five-year overall survival rate was 49% and 53%, respectively. Anastomotic leakage rate and 90-days mortality were 5% and 2%, respectively. Six patients (6%) had later surgery for metastases to mediastinum, hepatoduodenal ligament, brain, lung, liver or bladder median 26 months (4-51) after HE. Forty-one out of 51 patients alive (80%) filled out questionnaires after median 65.5 months (63-123) follow-up. All patients could eat normal food without (n = 37) or with (n = 4) problems. Nearly, half of the patients reported problems with reflux, one-third experienced fatigue and anxiety while one out of four had weight loss and episodes of dyspnea.Conclusions: In this patient series, HE offered low postoperative mortality and good overall long-term survival. Most survivors maintained good quality of life more than five years post treatment. There was a low rate of serious postoperative complications.

Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach

Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO₂/FiO₂ ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman's rank correlation coefficient (r_sp) = -0.267, p = 0.006), especially of laparotomy (r_sp = -0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1-25) and 8.5 (3-14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.

Unmet supportive care needs and associated factors among Chinese discharged patients with esophageal cancer after esophagectomy: A cross-sectional study

PURPOSE

After esophagectomy, patients experience a series of problems that severely affect their quality of life. Understanding their unmet needs could help medical staff provide better supportive care. The aim of this study was to investigate the supportive care needs of discharged patients with esophageal cancer after esophagectomy and explore the factors associated with these needs.

METHOD

A total of 167 discharged patients with esophageal cancer after esophagectomy were recruited from a University Cancer Center in China and investigated using a self-designed demographic and clinical characteristics questionnaire, the 34-item Supportive Care Needs Survey, and the M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module.

RESULTS

Approximately 95.2% of the patients had ≥1 unmet need(s). The overall level of supportive care needs of patients after esophagectomy was mild to medium. Most of the top 10 moderate-to-severe unmet needs were identified in the health and information domains. Age (β = -0.157, p = 0.011), dysphagia (β = -0.178, p = 0.005), recurrence (β = 0.175, p = 0.005), time since diagnosis (β = -0.150, p = 0.018), and symptom interference (β = 0.488, p < 0.001) were significantly associated with supportive care needs.

CONCLUSIONS

Discharged patients with esophageal cancer after esophagectomy had a wide range of unmet supportive care needs. It is essential to combine the associated factors to accurately evaluate patient needs. We should pay more attention to propose comprehensive measures for these patients and provide more individualized supportive care during the lengthy recovery period.