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Klevebro F, Ash S, Mueller C, Garbarino GM, Gisbertz SS, van Berge Henegouwen MI, Mandeville Y, Ferri L, Davies A, Maynard N, Low DE. Contemporary outcomes of left thoraco-abdominal esophagectomy due to cancer in the esophagus or gastroesophageal junction, a multicenter cohort study. Dis Esophagus 2024:doae039. [PMID: 38678385 DOI: 10.1093/dote/doae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
Surgery for cancer of the esophagus or gastro-esophageal junction can be performed with a variety of minimally invasive and open approaches. The left thoracoabdominal esophagectomy (LTE) is an open technique that gives an opportunity to operate in the chest and abdomen with excellent exposure of the gastro-esophageal junction through a single incision, and there is currently no equivalent minimally invasive technique available. The aim of this multi-institutional review was to study a large contemporary international study cohort of patients treated with LTE. An international multicenter cohort study was performed including all patients treated with LTE at six high-volume centers for gastro-esophageal cancer surgery between 2012 and 2022. Patient data were prospectively collected in each participating centers' institutional database. Information about patient, tumor, and treatment details were collected. The study cohort included a total of 793 patients treated with LTE during the study period. The most frequently observed complications were pneumonia in 185/727 (25.5%) patients and atrial fibrillation in 91/727 (12.5%). Anastomotic leak occurred in 35/727 (4.8%) patients; no patient suffered from conduit necrosis. Thirty-day mortality occurred in 15/785 (1.9%) patients and 90-day mortality in 39/785 (5.0%) patients. Factors with statistically significant association with survival were American Society for Anesthesiologists-score, tumor location, tumor stage, and tumor free resection margins. Neoadjuvant therapy was not associated with increased survival compared to surgery alone but neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy showed statistically significant improved survival with hazard ratio 0.60 (95% confidence intervals:0.44-0.80, P = 0.001) in a multivariable adjusted model. This study demonstrates that LTE can be applied in selected patients with results that are comparable to other large studies of open and minimally invasive surgery for esophageal or gastro-esophageal cancer at high-volume centers.
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Affiliation(s)
- F Klevebro
- Department for Thorqacic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
- CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - S Ash
- Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield Department of Medicine, University of Oxford Trust, Oxford, UK
| | - C Mueller
- Mc Gill University Health Center, Montreal, Canada
| | - G M Garbarino
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Sant' Andrea Hospital, Rome, Italy
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | | | - L Ferri
- Mc Gill University Health Center, Montreal, Canada
| | - A Davies
- St Thomas', King's College London, London, UK
| | - N Maynard
- Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield Department of Medicine, University of Oxford Trust, Oxford, UK
| | - D E Low
- Department for Thorqacic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
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Hultcrantz J, Klevebro F, Lindblad M, Brismar TB, Coy DL, Low DE, Andersson M. Improved radiologic diagnosis of delayed gastric conduit emptying (DGCE) after esophagectomy using a functional upper gastrointestinal contrast study. Acta Radiol 2024; 65:329-333. [PMID: 38111253 DOI: 10.1177/02841851231217990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND With increasing incidence of esophageal cancer, a growing number of patients are at risk of developing delayed gastric conduit emptying (DGCE) in the early postoperative phase after esophagectomy. This condition is of great postoperative concern due to its association with adverse outcomes. PURPOSE To give a narrative review of the literature concerning radiological diagnosis of DGCE after esophagectomy and a proposal for an improved, functional protocol with objective measurements. MATERIAL AND METHODS The protocol was designed at Virginia Mason Medical Center in Seattle and is based on the Timed Barium Esophagogram (TBE) concept, which has been adapted to assess the passage of contrast from the gastric conduit into the duodenum. RESULTS The literature review showed a general lack of standardization and scientific evidence behind the use of radiology to assess DGCE. We found that our proposed standardized upper gastrointestinal (UGI) contrast study considers both the time aspect in DGCE and provides morphologic information of the gastric conduit. This radiological protocol was tested on 112 patients in a trial performed at two high-volume centers for esophageal surgery and included an UGI contrast study 2-3 days postoperatively. The study demonstrated that this UGI contrast study can be included in the standardized clinical pathway after esophagectomy. CONCLUSION This new, proposed UGI contrast study has the potential to diagnose early postoperative DGCE in a standardized manner and to improve overall patient outcomes after esophagectomy.
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Affiliation(s)
- Jens Hultcrantz
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - David L Coy
- Department of Radiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Mats Andersson
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Huang B, Rampulla V, Ri M, Lindblad M, Nilsson M, Rouvelas I, Klevebro F. Staging laparoscopy with peritoneal lavage to identify peritoneal metastases and free intraperitoneal cancer cells in the management of locally advanced gastric cancer. Eur J Surg Oncol 2024; 50:108059. [PMID: 38503223 DOI: 10.1016/j.ejso.2024.108059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/06/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Gastric cancer often presents in advanced stage with a significant risk for peritoneal dissemination. Staging laparoscopy can be used to detect peritoneal carcinomatosis (PC+) and free cancer cells in peritoneal lavage cytology (CY+). The current study aimed to present the outcomes of staging laparoscopy and the prognosis of PC+ and CY+ in a Swedish high-volume center. MATERIALS AND METHODS A cohort study including all consecutive patients with locally advanced gastric cancer who underwent staging laparoscopy between February 2008 and October 2022. The laparoscopy findings were categorized as PC+, PC-CY+ (positive cytology without peritoneal carcinomatosis) or negative laparoscopy (PC-CY-). The primary endpoint was overall survival (OS) stratified by laparoscopy findings. The secondary endpoint was OS within each laparoscopy finding group stratified by subsequent treatment. RESULTS Among 168 patients who underwent staging laparoscopy, 78 patients (46%) had PC-CY-, 29 patients (17%) had PC-CY+ and 61 patients (36%) had PC+. Decreased OS was observed for both PC-CY+ patients (aHR 2.14, 95% CI 1.13-4.06) and PC+ patients (aHR 5.36, 95% CI 3.21-8.93), compared to PC-CY-. Patients with PC-CY+ who converted to PC-CY- after chemotherapy and underwent tumor resection seemed to have a better prognosis compared to patients with persisting PC-CY+. CONCLUSIONS Staging laparoscopy is an important tool in the staging of locally advanced gastric cancer. Tumor resection for patients with PC-CY+ who convert to PC-CY- may lead to improved survival for these patients.
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Affiliation(s)
- B Huang
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden.
| | - V Rampulla
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden; Surgical Oncology Unit, Surgical Department ASST Bergamo Ovest, Piazzale Ospedale 1, 24047 Treviglio, BG, Italy
| | - M Ri
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - M Lindblad
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - M Nilsson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - I Rouvelas
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - F Klevebro
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Center for Upper Gastrointestinal Diseases, C1.77, Karolinska University Hospital, 141 86 Stockholm, Sweden
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Mantziari S, Elliott JA, Markar SR, Klevebro F, Goense L, Johar A, Lagergren P, Zaninotto G, van Hillegersberg R, van Berge Henegouwen MI, Schäfer M, Nilsson M, Hanna GB, Reynolds JV. Sex-related differences in oncologic outcomes, operative complications and health-related quality of life after curative-intent oesophageal cancer treatment: multicentre retrospective analysis. BJS Open 2024; 8:zrae026. [PMID: 38568850 PMCID: PMC10989878 DOI: 10.1093/bjsopen/zrae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Oesophageal cancer, in particular adenocarcinoma, has a strong male predominance. However, the impact of patient sex on operative and oncologic outcomes and recovery of health-related quality of life is poorly documented, and was the focus of this large multicentre cohort study. METHODS All consecutive patients who underwent oncological oesophagectomy from 2009 to 2015 in the 20 European iNvestigation of SUrveillance after Resection for Esophageal cancer study group centres were assessed. Clinicopathologic variables, therapeutic approach, postoperative complications, survival and health-related quality of life data were compared between male and female patients. Multivariable analyses adjusted for age, sex, tumour histology, treatment protocol and major complications. Specific subgroup analyses comparing adenocarcinoma versus squamous cell cancer for all key outcomes were performed. RESULTS Overall, 3974 patients were analysed, 3083 (77.6%) male and 891 (22.4%) female; adenocarcinoma was predominant in both groups, while squamous cell cancer was observed more commonly in female patients (39.8% versus 15.1%, P < 0.001). Multivariable analysis demonstrated improved outcomes in female patients for overall survival (HRmales 1.24, 95% c.i. 1.07 to 1.44) and disease-free survival (HRmales 1.22, 95% c.i. 1.05 to 1.43), which was caused by the adenocarcinoma subgroup, whereas this difference was not confirmed in squamous cell cancer. Male patients presented higher health-related quality of life functional scores but also a higher risk of financial problems, while female patients had lower overall summary scores and more persistent gastrointestinal symptoms. CONCLUSION This study reveals uniquely that female sex is associated with more favourable long-term survival after curative treatment for oesophageal cancer, especially adenocarcinoma, although long-term overall and gastrointestinal health-related quality of life are poorer in women.
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Affiliation(s)
- Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne UNIL, Lausanne, Switzerland
| | - Jessie A Elliott
- Trinity St. James’s Cancer Institute, Trinity College Dublin, and St. James’s Hospital, Dublin, Ireland
| | - Sheraz R Markar
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
| | | | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Asif Johar
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | | | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne UNIL, Lausanne, Switzerland
| | - Magnus Nilsson
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
| | - John V Reynolds
- Trinity St. James’s Cancer Institute, Trinity College Dublin, and St. James’s Hospital, Dublin, Ireland
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Murad F, Klevebro F, Henriksson G, Rouvelas I, Lindblad M, Nilsson M. Management and outcomes in a consecutive series of patients with aero-digestive fistula at a tertiary gastro-esophageal surgery center. Dis Esophagus 2024; 37:doad068. [PMID: 38100731 PMCID: PMC10906709 DOI: 10.1093/dote/doad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 04/07/2023] [Accepted: 11/24/2023] [Indexed: 12/17/2023]
Abstract
Aerodigestive fistula (ADF) is defined as a pathological connection between the upper digestive tract and the airway. ADF is associated with high morbidity and mortality and management is often complex. A cohort study including all patients admitted with ADF 2004-2022 at a single tertiary esophageal surgery center was performed based on prospectively collected administrative data and retrospectively collected electronic patient chart data,. Patient demographics, performance status, comorbidity, fistula characteristics, management, and outcomes in terms of morbidity and mortality were assessed in patients with ADF of three distinct types: (i) tumor overgrowth-related, (ii) various benign etiologies, and (iii) post-esophagectomy. Sixty-one patients with ADF were included in the study, 33 (54.1%) tumor overgrowth-related, six (9.8%) benign and 22 (36.1%) post-esophagectomy. In the post-esophagectomy group 15 out of 22 (68.2%) patients were diagnosed with anastomotic leakage prior to ADF diagnosis. Self-expandable metallic stents (SEMS) were used for temporary fistula sealing in 59 out of 61 (96.7%) patients, of which most received stents in both the digestive tract and airway. Temporary fistula sealing with stents was successful enabling discharge from hospital in 47 out of 59 (79.7%) patients. Definitive ADF repair was performed in 16 (26.2%) patients, of which one (6.3%) died within 90-days and 15 could be discharged home with permanently sealed fistulas. ADF is a complex condition associated with high mortality, which often requires multiple advanced interventions. SEMS can be applied in the airway and simultaneously in the digestive tract to temporarily seal the ADF as bridge to definitive surgical repair.
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Affiliation(s)
- Fahad Murad
- Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Gert Henriksson
- Division of Ear, Nose and Throat Diseases, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Ear, Nose and Throat Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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Tsekrekos A, Borg D, Johansson V, Nilsson M, Klevebro F, Lundell L, Gustafsson-Liljefors M, Rouvelas I. Impact of Laparoscopic Gastrectomy on the Completion Rate of the Perioperative Chemotherapy Regimen in Gastric Cancer: A Swedish Nationwide Study. Ann Surg Oncol 2023; 30:7196-7205. [PMID: 37505355 PMCID: PMC10562295 DOI: 10.1245/s10434-023-13967-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Omission of prescheduled chemotherapy following surgery for gastric cancer is a frequent clinical problem. This study examined whether laparoscopic gastrectomy (LG) had a positive impact on compliance with adjuvant chemotherapy compared with open (OG). METHODS Patients with cT2-4aN0-3M0 adenocarcinoma treated with gastrectomy and perioperative chemotherapy between 2015 and 2020 were identified in the Swedish national register. Additional information regarding chemotherapy was retrieved from medical records. Regression models were used to investigate the association between surgical approach and the following outcomes: initiation of adjuvant chemotherapy, modification, and time interval from surgery to start of treatment. RESULTS A total of 247 patients were included (121 OG and 126 LG, conversion rate 11%), of which 71.3% had performance status ECOG 0 and 77.7% clinical stage II/III. In total, 86.2% of patients started adjuvant chemotherapy, with no significant difference between the groups (LG 88.1% vs OG 84.3%, p = 0.5). Reduction of chemotherapy occurred in 37.4% of patients and was similar between groups (LG 39.4% vs OG 35.1%, p = 0.6), as was the time interval from surgery. In multivariable analysis, LG was not associated with the probability of starting adjuvant chemotherapy (OR 1.36, p = 0.4) or the need for reduction (OR 1.29, p = 0.4). Conversely, major complications had a significant, negative impact on both outcomes. CONCLUSIONS This nationwide study demonstrated a high rate of adjuvant chemotherapy initiation after curative intended surgery for gastric cancer. A beneficial effect of LG compared with OG on the completion rate was not evident.
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Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden.
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - David Borg
- Oncology Department, Skåne University Hospital, Lund, Sweden
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Victor Johansson
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Maria Gustafsson-Liljefors
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Nilsson K, Klevebro F, Sunde B, Rouvelas I, Lindblad M, Szabo E, Halldestam I, Smedh U, Wallner B, Johansson J, Johnsen G, Aahlin EK, Johannessen HO, Alexandersson von Döbeln G, Hjortland GO, Wang N, Shang Y, Borg D, Quaas A, Bartella I, Bruns C, Schröder W, Nilsson M. Oncological outcomes of standard versus prolonged time to surgery after neoadjuvant chemoradiotherapy for oesophageal cancer in the multicentre, randomised, controlled NeoRes II trial. Ann Oncol 2023; 34:1015-1024. [PMID: 37657554 DOI: 10.1016/j.annonc.2023.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The optimal time to surgery (TTS) after neoadjuvant chemoradiotherapy (nCRT) for oesophageal cancer is unknown and has traditionally been 4-6 weeks in clinical practice. Observational studies have suggested better outcomes, especially in terms of histological response, after prolonged delay of up to 3 months after nCRT. The NeoRes II trial is the first randomised trial to compare standard to prolonged TTS after nCRT for oesophageal cancer. PATIENTS AND METHODS Patients with resectable, locally advanced oesophageal cancer were randomly assigned to standard delay of surgery of 4-6 weeks or prolonged delay of 10-12 weeks after nCRT. The primary endpoint was complete histological response of the primary tumour in patients with adenocarcinoma (AC). Secondary endpoints included histological tumour response, resection margins, overall and progression-free survival in all patients and stratified by histologic type. RESULTS Between February 2015 and March 2019, 249 patients from 10 participating centres in Sweden, Norway and Germany were randomised: 125 to standard and 124 to prolonged TTS. There was no significant difference in complete histological response between AC patients allocated to standard (21%) compared to prolonged (26%) TTS (P = 0.429). Tumour regression, resection margins and number of resected lymph nodes, total and metastatic, did not differ between the allocated interventions. The first quartile overall survival in patients allocated to standard TTS was 26.5 months compared to 14.2 months after prolonged TTS (P = 0.003) and the overall risk of death during follow-up was 35% higher after prolonged delay (hazard ratio 1.35, 95% confidence interval 0.94-1.95, P = 0.107). CONCLUSION Prolonged TTS did not improve histological complete response or other pathological endpoints, while there was a strong trend towards worse survival, suggesting caution in routinely delaying surgery for >6 weeks after nCRT.
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Affiliation(s)
- K Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - F Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - B Sunde
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - M Lindblad
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - E Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro
| | | | - U Smedh
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg
| | - B Wallner
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå
| | - J Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - G Johnsen
- Department of Gastrointestinal Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim
| | - E K Aahlin
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø
| | - H-O Johannessen
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - G Alexandersson von Döbeln
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm; Medical Unit of Head, Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - G O Hjortland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - N Wang
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm
| | - Y Shang
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm
| | - D Borg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - A Quaas
- Institute of Pathology, University of Cologne, Cologne
| | - I Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - C Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - W Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm.
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9
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Tsekrekos A, Borg D, Johansson V, Nilsson M, Klevebro F, Lundell L, Gustafsson-Liljefors M, Rouvelas I. ASO Visual Abstract: Impact of Laparoscopic Gastrectomy on the Completion Rate of the Perioperative Chemotherapy Regimen in Gastric Cancer: A Swedish Nationwide Study. Ann Surg Oncol 2023; 30:7257-7258. [PMID: 37610490 DOI: 10.1245/s10434-023-14181-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden.
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - David Borg
- Oncology Department, Skåne University Hospital, Lund, Sweden
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Victor Johansson
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Maria Gustafsson-Liljefors
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital C1:77, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Tsekrekos A, Borg D, Johansson V, Nilsson M, Klevebro F, Lundell L, Gustafsson-Liljefors M, Rouvelas I. ASO Author Reflections: The Impact of Minimally Invasive Surgery on the Completion Rate of the Perioperative Chemotherapy Protocol in Gastric Cancer. Ann Surg Oncol 2023; 30:7251-7252. [PMID: 37525004 PMCID: PMC10562288 DOI: 10.1245/s10434-023-14023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - David Borg
- Oncology Department, Skåne University Hospital, Lund, Sweden
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Victor Johansson
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Maria Gustafsson-Liljefors
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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11
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Holmén A, Jebril W, Ida S, Agustsson T, Lampi M, Rouvelas I, Sunde B, Klevebro F. Effects of neoadjuvant therapy on health-related quality of life for patients with gastroesophageal cancer. Eur J Surg Oncol 2023; 49:107008. [PMID: 37673022 DOI: 10.1016/j.ejso.2023.107008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/21/2023] [Accepted: 08/02/2023] [Indexed: 09/08/2023]
Abstract
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.
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Affiliation(s)
- Anders Holmén
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset AB, Stockholm, Sweden.
| | - William Jebril
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Ida
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Thorhallur Agustsson
- Department of Surgery, Södersjukhuset AB, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Maria Lampi
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Berit Sunde
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
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12
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Elliott JA, Klevebro F, Mantziari S, Markar SR, Goense L, Johar A, Lagergren P, Zaninotto G, van Hillegersberg R, van Berge Henegouwen MI, Schäfer M, Nilsson M, Hanna GB, Reynolds JV. Neoadjuvant Chemoradiotherapy Versus Chemotherapy for the Treatment of Locally Advanced Esophageal Adenocarcinoma in the European Multicenter ENSURE Study. Ann Surg 2023; 278:692-700. [PMID: 37470379 DOI: 10.1097/sla.0000000000006018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE This study aimed to compare clinicopathologic, oncologic, and health-related quality of life (HRQL) outcomes following neoadjuvant chemoradiation (nCRT) and chemotherapy (nCT) in the ENSURE international multicenter study. BACKGROUND nCT and nCRT are the standards of care for locally advanced esophageal cancer (LAEC) treated with curative intent. However, no published randomized controlled trial to date has demonstrated the superiority of either approach. METHODS ENSURE is an international multicenter study of consecutive patients undergoing surgery for LAEC (2009-2015) across 20 high-volume centers (NCT03461341). The primary outcome measure was overall survival (OS), secondary outcomes included histopathologic response, recurrence pattern, oncologic outcome, and HRQL in survivorship. RESULTS A total of 2211 patients were studied (48% nCT, 52% nCRT). pCR was observed in 4.9% and 14.7% ( P <0.001), with R0 in 78.2% and 94.2% ( P <0.001) post nCT and nCRT, respectively. Postoperative morbidity was equivalent, but in-hospital mortality was independently increased [hazard ratio (HR)=2.73, 95% CI: 1.43-5.21, P= 0.002] following nCRT versus nCT. Probability of local recurrence was reduced (odds ratio=0.71, 95% CI: 0.54-0.93, P =0.012), and distant recurrence-free survival time reduced (HR=1.18, 95% CI: 1.02-1.37, P =0.023) after nCRT versus nCT, with no difference in OS among all patients (HR=1.10, 95% CI: 0.98-1.25, P =0.113). On subgroup analysis, patients who underwent R0 resection following nCT as compared with nCRT had improved OS (median: 60.7 months, 95% CI: 49.5-71.8 vs 40.8 months, 95% CI: 42.8-53.4, P <0.001). CONCLUSIONS In this European multicenter study, nCRT compared with nCT was associated with reduced probability of local recurrence but reduced distant recurrence-free survival for patients with LAEC, without differences in OS. These data support tailored patient-specific decision-making in the overall approach to achieving optimum outcomes in LAEC.
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Affiliation(s)
- Jessie A Elliott
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
| | - Fredrik Klevebro
- CLINTEC, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Styliani Mantziari
- Lausanne University Hospital CHUV and University of Lausanne UNIL, Lausanne, Switzerland
| | - Sheraz R Markar
- Surgical Interventional Trials Unit, Nuffield Department of Surgery, University of Oxford, Oxford, UK
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Asif Johar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus Schäfer
- Lausanne University Hospital CHUV and University of Lausanne UNIL, Lausanne, Switzerland
| | - Magnus Nilsson
- CLINTEC, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - John V Reynolds
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
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13
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Ólafsdóttir HS, Dalqvist E, Onjukka E, Klevebro F, Nilsson M, Gagliardi G, Alexandersson von Döbeln G. Postoperative complications after esophagectomy for cancer, neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy: A single institutional cohort study. Clin Transl Radiat Oncol 2023; 40:100610. [PMID: 36936472 PMCID: PMC10018434 DOI: 10.1016/j.ctro.2023.100610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 03/07/2023] Open
Abstract
Background Complications after esophagectomy are common and the possible increase in postoperative complications associated with neoadjuvant chemoradiotherapy is of concern. The aim of our study was to analyze if the addition of radiotherapy to neoadjuvant chemotherapy increases the incidence and severity of postoperative complications, including evaluation of the relation between radiation doses to the heart and lungs and postoperative complications. Methods The study was based on an institutional surgical database for esophageal cancer. The study period was October 2008 to March 2020. Patients treated with neoadjuvant chemoradiotherapy were compared to patients treated with neoadjuvant chemotherapy and dose/volume parameters for the lungs and heart considered. The primary outcome was 30-day postoperative complications. Results During the study period, 274 patients underwent surgery for esophageal cancer, 93 patients after neoadjuvant chemotherapy and 181 patients after neoadjuvant chemoradiotherapy. The median prescribed radiation dose to the planning target volume was 41.4 Gy, the median of the mean lung dose was 6.2 Gy, and the median of the mean heart dose was 20.3 Gy. The addition of radiotherapy to neoadjuvant chemotherapy did not increase the incidence of postoperative complications. Neither were radiation doses to the lungs and heart associated with postoperative complications. Taxane-based chemotherapy regimens were however associated with an increased incidence of postoperative complications. Conclusions In our cohort, the addition of neoadjuvant radiotherapy to chemotherapy was not associated with postoperative complications. However, taxane-based chemotherapy regimens, with or without concomitant radiotherapy, were associated with postoperative complications.
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Affiliation(s)
- Halla Sif Ólafsdóttir
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, SE-141 52 Huddinge, Sweden
- Department of Radiotherapy, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-171 64 Solna, Sweden
- Corresponding author at: Department of Radiotherapy, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Anna Steckséns gata 41, SE-171 76 Stockholm, Sweden.
| | - Emmy Dalqvist
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-171 64 Solna, Sweden
| | - Eva Onjukka
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-171 64 Solna, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, SE-171 64 Solna, Sweden
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, SE-141 52 Huddinge, Sweden
- Department of Upper Abdominal Diseases, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-141 57 Huddinge, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, SE-141 52 Huddinge, Sweden
- Department of Upper Abdominal Diseases, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-141 57 Huddinge, Sweden
| | - Giovanna Gagliardi
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-171 64 Solna, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, SE-171 64 Solna, Sweden
| | - Gabriella Alexandersson von Döbeln
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, SE-141 52 Huddinge, Sweden
- Medical Unit of Head, Neck, Lung and Skin Cancer, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, SE-171 64 Solna, Sweden
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14
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Elliott JA, Markar SR, Klevebro F, Johar A, Goense L, Lagergren P, Zaninotto G, van Hillegersberg R, van Berge Henegouwen MI, Nilsson M, Hanna GB, Reynolds JV. An International Multicenter Study Exploring Whether Surveillance After Esophageal Cancer Surgery Impacts Oncological and Quality of Life Outcomes (ENSURE). Ann Surg 2023; 277:e1035-e1044. [PMID: 35129466 PMCID: PMC10082056 DOI: 10.1097/sla.0000000000005378] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the impact of surveillance on recurrence pattern, treatment, survival and health-related quality-of-life (HRQL) following curative-intent resection for esophageal cancer. SUMMARY BACKGROUND DATA Although therapies for recurrent esophageal cancer may impact survival and HRQL, surveillance protocols after primary curative treatment are varied and inconsistent, reflecting a lack of evidence. METHODS European iNvestigation of SUrveillance after Resection for Esophageal cancer was an international multicenter study of consecutive patients undergoing surgery for esophageal and esophagogastric junction cancers (2009-2015) across 20 centers (NCT03461341). Intensive surveillance (IS) was defined as annual computed tomography for 3 years postoperatively. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival, recurrence pattern, and HRQL. Multivariable linear, logistic, and Cox proportional hazards regression analyses were performed. RESULTS Four thousand six hundred eighty-two patients were studied (72.6% adenocarcinoma, 69.1% neoadjuvant therapy, 45.5% IS). At median followup 60 months, 47.5% developed recurrence, oligometastatic in 39%. IS was associated with reduced symptomatic recurrence (OR 0.17 [0.12-0.25]) and increased tumor-directed therapy (OR 2.09 [1.58-2.77]). After adjusting for confounders, no OS benefit was observed among all patients (HR 1.01 [0.89-1.13]), but OS was improved following IS for those who underwent surgery alone (HR 0.60 [0.47-0.78]) and those with lower pathological (y)pT stages (Tis-2, HR 0.72 [0.58-0.89]). IS was associated with greater anxiety ( P =0.016), but similar overall HRQL. CONCLUSIONS IS was associated with improved oncologic outcome in select cohorts, specifically patients with early-stage disease at presentation or favorable pathological stage post neoadjuvant therapy. This may inform guideline development, and enhance shared decision-making, at a time when therapeutic options for recurrence are expanding.
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Affiliation(s)
- Jessie A Elliott
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Asif Johar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Pernilla Lagergren
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - John V Reynolds
- Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland
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15
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Grip J, Norberg Å, Klevebro F. Limitations of reliance on metabolic markers following surgery. Acta Anaesthesiol Scand 2023; 67:562-563. [PMID: 36653963 DOI: 10.1111/aas.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Jonathan Grip
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
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16
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Klevebro F, Konradsson M, Han S, Luttikhold J, Nilsson M, Lindblad M, Andersson M, Low DE. ERAS guidelines-driven upper gastrointestinal contrast study after esophagectomy can detect delayed gastric conduit emptying and improve outcomes. Surg Endosc 2023; 37:1838-1845. [PMID: 36229553 PMCID: PMC10017562 DOI: 10.1007/s00464-022-09695-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/25/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric conduit emptying can occur after esophagectomy and has been shown to be associated with increased risk for postoperative complications. Application of a standardized clinical protocol after esophagectomy including an upper gastrointestinal contrast study has the potential to improve postoperative outcomes. METHODS Prospective cohort including all patients operated with esophagectomy at two high-volume centers for esophageal surgery. The standardized clinical protocol included an upper gastrointestinal contrast study on day 2 or 3 after surgery. All images were compiled and evaluated for the purpose of the study. Clinical data was collected in IRB approved institutional databases at the participating centers. RESULTS The study included 119 patients treated with esophagectomy of whom 112 (94.1%) completed an upper gastrointestinal contrast study. The results showed that 8 (7.1%) patients had radiological delayed gastric conduit emptying defined as no emptying of contrast through the pylorus. Partial conduit emptying was seen in 34 (30.4%) patients, and 70 (62.5%) patients had complete conduit emptying. Complete or partial emptying was associated with significantly earlier nasogastric tube removal (3 vs. 6 days) and hospital discharge 8 vs. 17 days, P < 0.001). Radiological signs of delayed gastric conduit emptying were shown to be associated with increased risk of postoperative complications. There was, however, no association with severe postoperative complications according to Clavien-Dindo score, pulmonary complications, anastomotic leak or need for intensive care. CONCLUSION The results of the study demonstrate that postoperative upper gastrointestinal contrast studies can be used to assess the level of emptying of the gastric conduit after esophagectomy. Application of upper gastrointestinal contrast study in the ERAS guidelines-driven standardized clinical pathway after esophagectomy has the potential to improve postoperative outcomes.
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Affiliation(s)
- F Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Halsov 13, 14186, Stockholm, Sweden.
| | - M Konradsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Halsov 13, 14186, Stockholm, Sweden
| | - S Han
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, USA
| | - J Luttikhold
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Halsov 13, 14186, Stockholm, Sweden
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Halsov 13, 14186, Stockholm, Sweden
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Halsov 13, 14186, Stockholm, Sweden
| | - M Andersson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - D E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, USA
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17
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Swartling O, Evans M, Larsson P, Gilg S, Holmberg M, Klevebro F, Löhr M, Sparrelid E, Ghorbani P. Risk factors for acute kidney injury after pancreatoduodenectomy, and association with postoperative complications and death. Pancreatology 2023; 23:227-233. [PMID: 36639282 DOI: 10.1016/j.pan.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy. METHODS All patients ≥18 years who underwent a pancreatoduodenectomy 2008-2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI. RESULTS In total, 970 patients were included with a median age of 68 years (IQR 61-74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24-5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39-13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54-13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37-10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88-12.71). CONCLUSIONS Postoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Marie Evans
- Renal Unit, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Larsson
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Löhr
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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18
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Linde H, Bartusevicius V, Norberg Å, Klevebro F, Grip J. Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications. Acta Anaesthesiol Scand 2023; 67:277-283. [PMID: 36537042 DOI: 10.1111/aas.14181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied. METHODS We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016-2018, n = 153. Most were performed with minimally invasive technique, n = 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately. RESULTS Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12-16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance. CONCLUSION In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.
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Affiliation(s)
- Henrik Linde
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Vilhelmas Bartusevicius
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Grip
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
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19
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Tsekrekos A, Vossen LE, Lundell L, Jeremiasen M, Johnsson E, Hedberg J, Edholm D, Klevebro F, Nilsson M, Rouvelas I. Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study. Gastric Cancer 2023; 26:467-477. [PMID: 36808262 PMCID: PMC10115725 DOI: 10.1007/s10120-023-01371-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/06/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer. METHODS Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression. RESULTS In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001). CONCLUSIONS Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.
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Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital, C1:77, Stockholm, Sweden. .,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
| | - Laura E Vossen
- Department of Upper Abdominal Surgery, Karolinska University Hospital, C1:77, Stockholm, Sweden.,Centre for Bioinformatics and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Martin Jeremiasen
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Erik Johnsson
- Department of Surgery, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Jakob Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Edholm
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Karolinska University Hospital, C1:77, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Karolinska University Hospital, C1:77, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital, C1:77, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
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20
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Klevebro F, Han S, Ash S, Mueller C, Cools-Lartigue J, Maynard N, Ferri L, Low D. Open left thoracoabdominal esophagectomy a viable option in the era of minimally invasive esophagectomy. Dis Esophagus 2022; 36:6576314. [PMID: 35511475 DOI: 10.1093/dote/doac024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/27/2022] [Indexed: 01/11/2023]
Abstract
Minimally invasive surgical technique has become standard at many institutions in esophageal cancer surgery. In some situations, however other surgical approaches are required. Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky distal esophageal tumors, but there are concerns that this approach is associated with significant morbidity. Prospectively entered esophagectomy databases from three high-volume centers were reviewed for patients undergoing LTE or MIE 2009-2019. Patient demographics, tumor characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 915 patients were included in the study, LTE was applied in 684 (74.8%) patients, and MIE in 231 (25.2%) patients. LTE patients had more locally advanced tumor stage and received more neoadjuvant treatment. Patients treated with MIE had more comorbidities. The results showed no difference in overall postoperative complications (LTE = 61.7%, MIE = 65.7%, P = 0.289), severe complications (Clavien-Dindo ≥IIIa (LTE = 25.9%, MIE 26.8%, P = 0.806)), pneumonia (LTE = 29.0%, MIE = 24.7%, P = 0.211), anastomotic leak (LTE = 7.8%, MIE = 11.3%, P = 0.101), or in-hospital mortality (LTE = 2.6%, MIE = 3.5%, P = 0.511). Median number of resected lymph nodes was 24 for LTE and 25 for MIE (P = 0.491). LTE was used for more advanced tumors in patients that were more likely to have received neoadjuvant treatment compared with MIE, however postoperative morbidity, mortality, and oncologic outcomes were equivalent to that of MIE in this cohort. In conclusion open resection with left thoracoabdominal approach is a valid option in selected patients when performed at high-volume esophagectomy centers.
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Affiliation(s)
- F Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA.,Department of Surgery, CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - S Han
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA
| | - S Ash
- Department of Medicine, Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield, University of Oxford Trust, Oxford, UK
| | - C Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - J Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - N Maynard
- Department of Medicine, Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield, University of Oxford Trust, Oxford, UK
| | - L Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA
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21
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Puccetti F, Klevebro F, Kuppusamy M, Han S, Fagley RE, Low DE, Hubka M. Analysis of Compliance with Enhanced Recovery After Surgery (ERAS) Protocol for Esophagectomy. World J Surg 2022; 46:2839-2847. [PMID: 36138318 DOI: 10.1007/s00268-022-06722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND ERAS guidelines have provided an effective recovery approach for esophagectomy. This study aimed to identify the relationship between the length of hospital stay (LOS) and compliance with clinical benchmarks of an established institutional ERAS program. METHODS A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2016 and January 2020. All patients underwent surgery within a standardized ERAS pathway for esophagectomy. Compliance with individual ERAS benchmarks and postoperative outcomes were evaluated according to patient's LOS; accelerated (≤ 6 days, AR), targeted (7-8 days, TR), and delayed recovery (≥ 9 days, DR). RESULTS The study included 100 consecutive patients undergoing esophagectomy with a median LOS of 7 (3.8-40.8) days, and a 30-day readmission rate of 12.6%. LOS was not affected by comorbidities, tumor type or stage, neoadjuvant therapy, operative approach or anastomotic leak. Postoperative complications were 49.5%, and 90-day mortality was 3.8%. AR, TR, and DL were achieved by 45%, 31%, and 24% of patients, respectively. Postoperative morbidity differed significantly among groups, impacting LOS (p < 0.001). Overall compliance with ERAS protocol was 82.7% and adherence to specific benchmarks was initially (< 48 h) high, but significantly affected by postoperative complications afterwards. CONCLUSIONS Adherence to recovery benchmarks in patients undergoing esophagectomy is most commonly impacted by postoperative complications. In esophageal cancer surgery, the adherence to ERAS benchmarks after esophagectomy should be regularly audited. Modification to ERAS protocols to increase application in patients with complications should be considered.
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Affiliation(s)
- Francesco Puccetti
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Eugeniavägen 3, 171 76, Solna, Stockholm, Sweden
| | - MadhanKumar Kuppusamy
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA
| | - Shiwei Han
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA
| | - Richard E Fagley
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA
| | - Michal Hubka
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA.
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22
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Larsson P, Feldt K, Holmberg M, Swartling O, Sparrelid E, Klevebro F, Ghorbani P. Preoperative heart disease and risk for postoperative complications after pancreatoduodenectomy. HPB (Oxford) 2022; 24:1854-1860. [PMID: 35872123 DOI: 10.1016/j.hpb.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/11/2022] [Accepted: 07/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Comorbidities increase the risk for postoperative complications after pancreatoduodenectomy. The importance of different categories of heart disease on postoperative outcomes has not been thoroughly studied. METHODS Patients aged ≥18 years undergoing pancreatoduodenectomy between 2008 and 2019 at Karolinska University Hospital, Sweden were included. Heart disease was defined as a preoperatively established diagnosis, and subcategorized into ischaemic, valvular, heart failure and atrial fibrillation. Postoperative outcome was analysed by multivariable regression. RESULTS Out of 971 patients, 225 (23.3%) had heart disease. Heart disease was associated with an increased risk for complications; Clavien-Dindo score ≥ IIIa (Odds Ratio [OR] 1.53, 95% confidence interval [CI] 1.07-2.18; p = 0.019), intensive care unit admissions (OR 3.20, 95% CI 1.81-5.66; p < 0.001) and longer hospitalizations (median 14 vs. 11 days; p < 0.001). Although heart disease was not associated with 90-day mortality, it conferred a shorter median overall survival (22 vs. 32 months; p < 0.001). Atrial fibrillation and heart failure were each associated with increased risk for postoperative complications, whereas ischaemic and valvular heart disease were not. CONCLUSION Atrial fibrillation and heart failure were independently associated with increased risk for postoperative complications. Despite no association with early postoperative mortality, heart disease negatively affected long-term survival.
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Affiliation(s)
- Patrik Larsson
- Department of Surgery, Skelleftea County Hospital, Skelleftea, Sweden; Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Kari Feldt
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Holmberg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Oskar Swartling
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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23
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Kauppila JH, Rosenlund H, Klevebro F, Johar A, Anandavadivelan P, Mälberg K, Lagergren P. Minimally invasive surgical techniques for oesophageal cancer and nutritional recovery: a prospective population-based cohort study. BMJ Open 2022; 12:e058763. [PMID: 36581984 PMCID: PMC9438117 DOI: 10.1136/bmjopen-2021-058763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To explore whether the minimally invasive oesophagectomy (MIE) or hybrid minimally invasive oesophagectomy (HMIE) are associated with better nutritional status and less weight loss 1 year after surgery, compared with open oesophagectomy (OE). DESIGN Prospective cohort study. SETTING All patients undergoing oesophagectomy for cancer in Sweden during 2013-2018. PARTICIPANTS A total of 424 patients alive at 1 year after surgery were eligible, and 281 completed the 1-year assessment. Of these, 239 had complete clinical data and were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was nutritional status at 1 year after surgery, assessed using the abbreviated Patient-Generated Subjective Global Assessment questionnaire. The secondary outcomes included postoperative weight loss at 6 months and 1 year after surgery. RESULTS Of the included patients, 78 underwent MIE, 74 HMIE while 87 patients underwent OE. The MIE group had the highest prevalence of malnutrition (42% vs 22% after HMIE vs 25% after OE), reduced food intake (63% vs 45% after HMIE vs 39% after OE), symptoms reducing food intake (60% vs 45% after HMIE vs 60% after OE) and abnormal activities/function (45% vs 32% after HMIE vs 43% after OE). After adjustment for confounders, MIE was associated with a statistically significant increased risk of reduced food intake 1 year after surgery (OR 2.87, 95% CI 1.47 to 5.61), compared with OE. Other outcomes were not statistically significantly different between the groups. No statistically significant associations were observed between surgical techniques and weight loss up to 1 year after surgery. CONCLUSIONS MIE was statistically significantly associated with reduced food intake 1 year after surgery. However, no differences were observed in weight loss between the surgical techniques. Further studies on nutritional impact of surgical techniques in oesophageal cancer are needed.
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Affiliation(s)
- Joonas H Kauppila
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Helen Rosenlund
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Orthopaedics, Danderyds Sjukhus AB, Stockholm, Sweden
| | - Fredrik Klevebro
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Asif Johar
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Poorna Anandavadivelan
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kalle Mälberg
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Surgical Care Sciences, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery & Cancer, Imperial College London, London, UK
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24
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Nilsson M, Olafsdottir H, Alexandersson von Döbeln G, Villegas F, Gagliardi G, Hellström M, Wang QL, Johansson H, Gebski V, Hedberg J, Klevebro F, Markar S, Smyth E, Lagergren P, Al-Haidari G, Rekstad LC, Aahlin EK, Wallner B, Edholm D, Johansson J, Szabo E, Reynolds JV, Pramesh CS, Mummudi N, Joshi A, Ferri L, Wong RKS, O’Callaghan C, Lukovic J, Chan KKW, Leong T, Barbour A, Smithers M, Li Y, Kang X, Kong FM, Chao YK, Crosby T, Bruns C, van Laarhoven H, van Berge Henegouwen M, van Hillegersberg R, Rosati R, Piessen G, de Manzoni G, Lordick F. Neoadjuvant Chemoradiotherapy and Surgery for Esophageal Squamous Cell Carcinoma Versus Definitive Chemoradiotherapy With Salvage Surgery as Needed: The Study Protocol for the Randomized Controlled NEEDS Trial. Front Oncol 2022; 12:917961. [PMID: 35912196 PMCID: PMC9326032 DOI: 10.3389/fonc.2022.917961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background The globally dominant treatment with curative intent for locally advanced esophageal squamous cell carcinoma (ESCC) is neoadjuvant chemoradiotherapy (nCRT) with subsequent esophagectomy. This multimodal treatment leads to around 60% overall 5-year survival, yet with impaired post-surgical quality of life. Observational studies indicate that curatively intended chemoradiotherapy, so-called definitive chemoradiotherapy (dCRT) followed by surveillance of the primary tumor site and regional lymph node stations and surgery only when needed to ensure local tumor control, may lead to similar survival as nCRT with surgery, but with considerably less impairment of quality of life. This trial aims to demonstrate that dCRT, with selectively performed salvage esophagectomy only when needed to achieve locoregional tumor control, is non-inferior regarding overall survival, and superior regarding health-related quality of life (HRQOL), compared to nCRT followed by mandatory surgery, in patients with operable, locally advanced ESCC. Methods This is a pragmatic open-label, randomized controlled phase III, multicenter trial with non-inferiority design with regard to the primary endpoint overall survival and a superiority hypothesis for the experimental intervention dCRT with regard to the main secondary endpoint global HRQOL one year after randomization. The control intervention is nCRT followed by preplanned surgery and the experimental intervention is dCRT followed by surveillance and salvage esophagectomy only when needed to secure local tumor control. A target sample size of 1200 randomized patients is planned in order to reach 462 events (deaths) during follow-up. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT04460352.
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Affiliation(s)
- Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
- *Correspondence: Magnus Nilsson,
| | - Halla Olafsdottir
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Gabriella Alexandersson von Döbeln
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Thoracic Oncology Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Fernanda Villegas
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Giovanna Gagliardi
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Hellström
- Center for Clinical Cancer Studies, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Qiao-Li Wang
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hemming Johansson
- Center for Clinical Cancer Studies, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Jakob Hedberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Sheraz Markar
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth Smyth
- Department of Oncology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Lars Cato Rekstad
- Department of Gastrointestinal Surgery, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eirik Kjus Aahlin
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Bengt Wallner
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - David Edholm
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Jan Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Eva Szabo
- Department of Surgery, University Hospital of Örebro, Örebro, Sweden
| | - John V. Reynolds
- Department of Surgery, Trinity St James’s Cancer Institute, Dublin, Ireland
| | - CS Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Naveen Mummudi
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Amit Joshi
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Lorenzo Ferri
- Department of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Rebecca KS Wong
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | | | - Jelena Lukovic
- Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Kelvin KW Chan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Trevor Leong
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Barbour
- Academy of Surgery, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mark Smithers
- Academy of Surgery, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Yin Li
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaozheng Kang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng-Ming Kong
- Thoracic Oncology Center, HKU Shenzhen Hospital, Hong Kong University Li Ka Shing Medical School, Shenzhen, China
| | - Yin-Kai Chao
- Department of thoracic surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tom Crosby
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, United Kingdom
| | - Christiane Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Hanneke van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Rafaele Hospital, Vita Salute University, Milan, Italy
| | - Guillaume Piessen
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER – Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000 Lille, France
| | | | - Florian Lordick
- University Cancer Center Leipzig, Leipzig University Medical Center, Leipzig, Germany
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Boshier PR, Klevebro F, Schmidt A, Han S, Jenq W, Puccetti F, Seesing MFJ, Baracos VE, Low DE. ASO Visual Abstract: Impact of Early Jejunostomy Tube Feeding on Clinical Outcome and Parameters of Body Composition in Esophageal Cancer Patients Receiving Multimodal Therapy. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-022-11815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cabrit N, Faron M, Tierney J, Cheugoua-Zanetsie M, Thirion P, Cunningham D, Winter K, Fu J, Mauer M, Shapiro J, Burmeister B, Walsh T, Piessen G, Klevebro F, Ychou M, Van Der Gaast A, Law S, Stahl M, Paoletti X, Ducreux M, Michiels S. SO-5 Disease-free survival as surrogate for overall survival in neoadjuvant chemo(radio)therapy treatment of esophageal or gastro-esophageal junction carcinoma: An analysis of 4518 individual patients and 22 trials. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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27
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Faron M, Cheugoua-Zanetsie M, Thirion P, Tierney J, Cunningham D, Winter K, Fu J, Mauer M, Shapiro J, Burmeister B, Walsh T, Piessen G, Klevebro F, Ychou M, Van Der Gaast A, Law S, Stahl M, van Sandick J, Pignon J, Ducreux M, Michiels S. SO-4 Individual participant data network meta-analysis (IPD-NMA) of neoadjuvant chemotherapy or chemoradiotherapy in esophageal or gastro-esophageal junction carcinoma. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Boshier PR, Klevebro F, Schmidt A, Han S, Jenq W, Puccetti F, Seesing MFJ, Baracos VE, Low DE. Impact of Early Jejunostomy Tube Feeding on Clinical Outcome and Parameters of Body Composition in Esophageal Cancer Patients Receiving Multimodal Therapy. Ann Surg Oncol 2022; 29:5689-5697. [PMID: 35616747 DOI: 10.1245/s10434-022-11754-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Malnutrition commonly affects patients with esophageal cancer and has the potential to negatively influence treatment outcomes. The aim of this study was to investigate the impact of early (preoperative) jejunostomy tube feeding (JTF) in nutritionally 'high risk' patients receiving multimodal therapy for esophageal cancer. METHODS Patients were selected to undergo early JTF during neoadjuvant chemoradiotherapy (nCRT) in accordance with European Society for Clinical Nutrition and Metabolism (ESPEN) and Enhanced Recovery after Surgery (ERAS®) Society guidelines. Clinical outcomes were compared with patients who received routine JTF from the time of esophagectomy. Body composition was determined from computed tomography (CT) images acquired at diagnosis, after nCRT, and ≥ 3 months after surgery. RESULTS In total, 81 patients received early JTF and 91 patients received routine JTF. Patients who received early JTF had lower body mass index (BMI; 26.1 ± 4.6 vs. 28.4 ± 4.9; p = 0.002), greater weight loss, and worse performance status at diagnosis. Groups were otherwise well-matched for baseline characteristics. Rate of re-intubation (8.8% vs. 1.1%; p = 0.027), pulmonary embolism (5.0% vs. 0.0%; p = 0.046), and 90-day mortality (10.0% vs. 1.1%; p = 0.010) were worse in the early JTF group; however, overall survival was equivalent for both the early and routine JTF groups (p = 0.053). Wide variation in the degree of preoperative muscle loss and total adipose tissue loss was observed across the entire study cohort. Relative preoperative muscle and adipose tissue loss in patients with early and routine JTF was equivalent. CONCLUSIONS In patients determined to be at 'high risk' of malnutrition, early JTF may prevent excess morbidity after esophagectomy with an associated relative preservation of parameters of body composition.
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Affiliation(s)
- Piers R Boshier
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Fredrik Klevebro
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Amy Schmidt
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shiwei Han
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Wesley Jenq
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Francesco Puccetti
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Maarten F J Seesing
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vickie E Baracos
- Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Donald E Low
- Department of Thoracic Surgery and Surgical Oncology, Virginia Mason Medical Center, Seattle, WA, USA.
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29
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Boshier PR, Klevebro F, Savva KV, Waller A, Hage L, Hanna GB, Low DE. Assessment of Health Related Quality of Life and Digestive Symptoms in Long-term, Disease Free Survivors After Esophagectomy. Ann Surg 2022; 275:e140-e147. [PMID: 32068555 DOI: 10.1097/sla.0000000000003829] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate long-term HRQOL and symptom evolution in disease free patients up to 20 years after esophagectomy. BACKGROUND Esophagectomy has been associated with decreased HRQOL and persistent gastrointestinal symptoms. METHODS The study cohort was identified from 2 high volume centers for the management of esophageal cancer. Patients completed HRQOL and symptom questionnaires, including: Digestive Symptom Questionnaire, EORTC QLQ-C30, EORTC QLQ-OG25 Euro QoL 5D, and SF36. Patients were assessed in 3 cohorts: <1 year; 1-5 years, and; >5 years after surgery. RESULTS In total 171 of 222 patients who underwent esophagectomy between 1991 and 2017 who met inclusion criteria and were contactable, responded to the questionnaires, corresponding to a response rate of 77%. Median age was 66.2 years, and median time from operation to survey was 5.6 years (range 0.3-23.1). Early satiety was the most commonly reported symptom in all patients irrespective of timeframe (87.4%; range 82%-92%). Dysphagia was seen to decrease over time (58% at <2 years; 28% at 2-5 years; 20% at >5 years; P = 0.013). Weight loss scores demonstrated nonstatistical improvement over time. All other symptom scores including heartburn, regurgitation, respiratory symptoms, and pain scores remained constant over time. Average HRQOL did not improve from levels 1 year after surgery compared to patients up to 23 years after esophagectomy. CONCLUSION With the exception of dysphagia, which improved over time, esophagectomy was associated with decreased HRQOL and lasting gastrointestinal symptoms up to 20 years after surgery. Pertinently however long-term survivors after oesophagectomy demonstrated comparable to improved HRQOL compared to the general population. The impact of esophagectomy on gastrointestinal symptoms and long-term HRQOL should be considered when counseling and caring for patients undergoing esophagectomy.
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Affiliation(s)
- Piers R Boshier
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery and Cancer, Imperial College London, UK
| | - Fredrik Klevebro
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, Karolinska Institutet, Sweden
| | | | - Anabelle Waller
- Department of Surgery and Cancer, Imperial College London, UK
| | - Lory Hage
- Department of Surgery and Cancer, Imperial College London, UK
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, UK
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA
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30
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Eyck BM, Klevebro F, van der Wilk BJ, Johar A, Wijnhoven BPL, van Lanschot JJB, Lagergren P, Markar SR, Lagarde SM. Lasting symptoms and long-term health-related quality of life after totally minimally invasive, hybrid and open Ivor Lewis esophagectomy. Eur J Surg Oncol 2021; 48:582-588. [PMID: 34763951 DOI: 10.1016/j.ejso.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/12/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
AIM Compared to open esophagectomy (OE), both totally minimally invasive (TMIE) and laparoscopy-assisted hybrid minimally invasive (HMIE) reduce postoperative morbidity and improve short-term health-related quality of life (HRQoL). We aimed to compare lasting symptoms and long-term HRQoL in an international population-based setting between patients who underwent Ivor Lewis TMIE, HMIE or OE. METHODS Patients who were relapse-free at least one year after TMIE, HMIE or OE for esophageal or junctional carcinoma between January 2010 and June 2016 were included. Patients completed the LASER questionnaire to assess lasting symptoms after esophagectomy and the EORTC QLQ-C30 and QLQ-OG25 questionnaires to assess HRQoL. Primary endpoint was chest pain and secondary endpoints were pain from chest scars or abdominal scars, abdominal pain, fatigue and physical functioning. Differences in lasting symptoms and HRQoL were assessed with multivariable logistic and ANCOVA regression, respectively. RESULTS A total of 362 patients were included (TMIE n = 91, HMIE n = 85, OE n = 186). Median follow-up was 3.9 years (IQR 2.8-5.4). Chest pain was reported less after TMIE compared with HMIE (adjusted OR 0.21, 95% CI 0.05-0.84), but was comparable between TMIE and OE (adjusted OR 0.41, 95% CI 0.12-1.41) and between HMIE and OE (adjusted OR 1.85, 95% CI 0.71-4.81). All secondary endpoints were comparable between TMIE, HMIE and OE. The impact of symptoms on taking medication, return to work, and performance status were comparable between groups. CONCLUSION Surgical technique seems to have little effect on lasting symptoms and long-term HRQoL after a median of four years after Ivor Lewis esophagectomy.
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Affiliation(s)
- Ben M Eyck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Fredrik Klevebro
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Berend J van der Wilk
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Asif Johar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Jan B van Lanschot
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sheraz R Markar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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Hayami M, Klevebro F, Tsekrekos A, Samola Winnberg J, Kamiya S, Rouvelas I, Nilsson M, Lindblad M. Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience. Dis Esophagus 2021; 34:6046267. [PMID: 33367786 DOI: 10.1093/dote/doaa122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.
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Affiliation(s)
- Masaru Hayami
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Johanna Samola Winnberg
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Kamiya
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Ólafsdóttir HS, Klevebro F, Ndegwa N, Alexandersson von Döbeln G. Short-course compared to long-course palliative radiotherapy for oesophageal cancer: a single centre observational cohort study. Radiat Oncol 2021; 16:153. [PMID: 34399793 PMCID: PMC8365913 DOI: 10.1186/s13014-021-01880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Common symptoms of oesophageal cancer are dysphagia, pain, and bleeding. These symptoms can be relieved with palliative radiotherapy. The aim of this study was to analyse the outcome of two different palliative radiotherapy schedules. Methods We conducted a retrospective cohort study on palliative radiotherapy for oesophageal cancer given at Karolinska University Hospital. Patients included were treated with either short-course (20 Gy in 4 Gy fractions daily, 5 consecutive workdays) or long-course (30–39 Gy in 3 Gy fractions, 10–13 consecutive workdays) palliative external beam radiotherapy between January 2009 and December 2013. The primary endpoint was dysphagia relief and secondary endpoints were adverse events, re-interventions, and overall survival. Cox regression analyses were used to estimate the effect of treatment schedule on survival. Results A total of 128 patients received external beam radiotherapy under the study period, of these 75 (58.6%) received short-course radiotherapy and 53 (41.4%) long-course radiotherapy. Sixteen (30.8%) patients experienced dysphagia relief after short-course radiotherapy and 9 (22.0%) patients after long-course radiotherapy (p = 0.341). Acute toxicity was less frequent after short-course radiotherapy than after long-course radiotherapy, particularly oesophagitis (35.4% vs. 56.0%, p = 0.027) and nausea/emesis (18.5% vs. 36.0% p = 0.034). Re-interventions tended to be more common after short-course radiotherapy (32.0%) than after long-course radiotherapy (18.9%) (p = 0.098). There was no difference in overall survival between the two groups. Conclusions Short- and long-course palliative radiotherapy for oesophageal cancer were equally effective to relieve dysphagia and no difference was seen in overall survival. Acute toxicity was, however, more frequent and more severe after long-course radiotherapy. Our results suggest that short-course radiotherapy is better tolerated with equal palliative effects as long-course radiotherapy.
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Affiliation(s)
- Halla Sif Ólafsdóttir
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden. .,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden.
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden
| | - Nelson Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Gabriella Alexandersson von Döbeln
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden.,Cancer Theme, Karolinska University Hospital, 171 64, Stockholm, Sweden
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33
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Klevebro F, Boshier PR, Savva KV, Waller A, Hage L, Ni M, Hanna GB, Low DE. Severe Dumping Symptoms Are Uncommon Following Transthoracic Esophagectomy But Significantly Decrease Health-Related Quality of Life in Long-Term, Disease-Free Survivors. J Gastrointest Surg 2021; 25:1941-1947. [PMID: 33150488 PMCID: PMC8321973 DOI: 10.1007/s11605-020-04670-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 05/25/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-quality documentation of dumping symptoms after esophagectomy is currently limited. The aim of the study was to describe the incidence of symptoms associated with dumping syndrome and their relationship with health-related quality of life after esophagectomy. METHODS The study cohort was identified from prospective IRB-approved databases from two high-volume esophagectomy centers. Patients that were alive and without evidence of recurrence in April 2018 completed the validated Dumping Symptom Rating Scale and health-related quality of life questionnaires. Compound dumping symptom score was created by combining the individual scores for severity and frequency for each symptom. RESULTS In total, 171 patients who underwent esophagectomy 1995-2017 responded to the questionnaires, corresponding to a response rate of 77.0%. Median age was 66 years and median time from operation to survey was 5.5 years. Absent or mild problems in all nine dumping symptoms were reported by 94 (59.5%) patients; 19 (12.0%) patients reported moderate or severe problems in at least three symptoms, the most common being postprandial "need to lie down," "diarrhea," and "stomach cramps." Increasing compound dumping symptom score was associated with significantly decreased function scores in all aspects of health-related quality of life except physical functioning (P < 0.005). CONCLUSIONS Esophagectomy has the potential to change long-term eating patterns; however, the majority of patients in the study did not have severe postoperative dumping symptoms. On the other hand, moderate-to-severe dumping symptoms, which were reported by 12% of patients in this study, were strongly associated with decreased health-related quality of life.
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Affiliation(s)
- F. Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101 USA
- Karolinska Institutet, Stockholm, Sweden
| | - P. R. Boshier
- Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101 USA
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - K. V. Savva
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A. Waller
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - L. Hage
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - M. Ni
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - G. B. Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Donald E. Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101 USA
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34
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Klevebro F, Kauppila JH, Markar S, Johar A, Lagergren P. Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study. Br J Surg 2021; 108:702-708. [PMID: 34157084 PMCID: PMC10364862 DOI: 10.1002/bjs.11998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/11/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Minimally invasive oesophagectomy has been shown to reduce the risk of pulmonary complications compared with open oesophagectomy, but the effects on health-related quality of life (HRQoL) and oesophageal cancer survivorship remain unclear. The aim of this study was to assess the longitudinal effects of minimally invasive compared with open oesophagectomy for cancer on HRQoL. METHODS All patients who had surgery for oesophageal cancer in Sweden from January 2013 to April 2018 were identified. The exposure was total or hybrid minimally invasive oesophagectomy, compared with open surgery. The study outcome was HRQoL, evaluated by means of the European Organisation for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-OG25 at 1 and 2 years after surgery. Mean differences and 95 per cent confidence intervals were adjusted for confounders. RESULTS Of the 246 patients recruited, 153 underwent minimally invasive oesophagectomy, of which 75 were hybrid minimally invasive and 78 were total minimally invasive procedures. After adjustment for age, sex, Charlson Co-morbidity Index score, pathological tumour stage and neoadjuvant therapy, there were no clinically and statistically significant differences in overall or disease-specific HRQoL after oesophagectomy between hybrid minimally invasive and total minimally invasive surgical technique versus open surgery. CONCLUSION In this population-based nationwide Swedish study, longitudinal HRQoL after minimally invasive oesophagectomy was similar to that of the open surgical approach.
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Affiliation(s)
- F Klevebro
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J H Kauppila
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Research Unit of Surgery, Anaesthesia and Intensive Care, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - S Markar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Johar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
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Elliott JA, Markar S, Klevebro F, Johar A, Goense L, Lowery MA, Lagergren P, Zaninotto G, van Hillegersberg R, Nilsson M, Hanna G, Reynolds JV. ENSURE: An international multicenter study exploring whether surveillance after esophageal cancer surgery impacts oncological and quality-of-life outcomes. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.4032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4032 Background: Although established and emerging therapies for recurrent esophageal cancer (EC) may impact on survival and health related quality of life (HRQL), surveillance protocols after the primary curative treatment of EC are varied and inconsistent, reflecting a limited evidence-base to guide an optimum approach. Specifically, whether advantages exist for an intensive surveillance protocol is unknown and was the focus of this study. Methods: European iNvestigation of SUrveillance after Resection for Esophageal cancer (ENSURE) is an international multicenter retrospective observational study of consecutive patients undergoing surgery with curative intent for esophageal and gastroesophageal junction cancers (2009 – 2015) across 20 European and North American cancer centers (NCT03461341). Intensive surveillance (IS) was defined as routine annual CT/PET-CT along with clinical assessment during the first three postoperative years, and compared with standard surveillance (SS) with investigation as clinically indicated. The primary outcome measure was overall survival (OS), secondary outcomes included treatment administered, disease-specific survival (DSS), disease-free survival (DFS), recurrence pattern, and HRQL. Multivariable linear, logistic and Cox proportional hazards regression analyses were performed to determine the independent impact of surveillance on oncologic outcomes and HRQL. Results: 4,682 patients were studied (72.6% adenocarcinoma, 69.1% neoadjuvant therapy). 45.5% underwent IS. At a median follow-up of 60 months, 47.5% developed disease recurrence. Oligometastatic recurrence occurred in 39% of cases, with 31% receiving best supportive care, 60% chemotherapy and/or radiation, and 8% surgical resection. IS was associated with reduced symptomatic recurrence (odds ratio [OR] 0.17 [0.12–0.25]), increased tumor-directed therapy (OR 2.09 [1.58–2.77]), and improved OS (HR 0.90 [0.82–0.98], 5-year OS 47.9±1.2% versus 43.2±1.1%). After adjusting for confounders, significantly improved overall survival with IS was maintained for patients who underwent surgery alone as initial therapy (HR 0.60 [0.47–0.78]) and in those with lower pathological (y)pT stages (Tis-2, HR 0.72 [0.58–0.89]). IS was associated with greater anxiety ( P= 0.016), but similar overall HRQL. Conclusions: These data suggest that IS may improve oncologic outcomes, particularly in patients with early stage disease at presentation or with a favorable pathological stage post induction therapy. This may be relevant to guideline development and provide a framework and rationale for RCTs. It may also inform shared decision-making with patients at a time where therapeutic options for recurrence are expanding.
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Affiliation(s)
| | - Sheraz Markar
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Asif Johar
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Pernilla Lagergren
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, 10th Floor, QEQM building, St. Mary’s Hospital, London, United Kingdom
| | | | - Magnus Nilsson
- Division of Surgery, CLINTEC, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - George Hanna
- St. Mary's Hospital, Imperial College, London, United Kingdom
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36
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Markar SR, Sounderajah V, Johar A, Zaninotto G, Castoro C, Lagergren P, Elliott JA, Gisbertz SS, Mariette C, Alfieri R, Huddy J, Pinto E, Scarpa M, Klevebro F, Sunde B, Murphy CF, Greene C, Ravi N, Piessen G, Brenkman H, Ruurda J, van Hillegersberg R, Lagarde SM, Wijnhoven BP, Pera M, Roigg J, Castro S, Matthijsen R, Findlay J, Antonowicz S, Maynard N, McCormack O, Ariyarathenam A, Sanders G, Cheong E, Jaunoo S, Allum W, van Lanschot J, Nilsson M, Reynolds JV, van Berge Henegouwen MI, Hanna GB. Patient-reported outcomes after oesophagectomy in the multicentre LASER study. Br J Surg 2021; 108:1090-1096. [PMID: 33975337 PMCID: PMC10364861 DOI: 10.1093/bjs/znab124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 03/19/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life. METHODS This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models. RESULTS Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms. CONCLUSION A long-term symptom burden is common after oesophageal cancer surgery.
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Affiliation(s)
- S R Markar
- Department Surgery and Cancer, Imperial College London, London, UK.,Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - V Sounderajah
- Department Surgery and Cancer, Imperial College London, London, UK
| | - A Johar
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - G Zaninotto
- Department Surgery and Cancer, Imperial College London, London, UK
| | - C Castoro
- Unit of Surgical Oncology of the Oesophagus and Digestive Tract, Veneto Institute of Oncology, Padua, Italy
| | - P Lagergren
- Department Surgery and Cancer, Imperial College London, London, UK.,Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J A Elliott
- Department of Surgery, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - S S Gisbertz
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C Mariette
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, F-59000 Lille, France
| | - R Alfieri
- Unit of Surgical Oncology of the Oesophagus and Digestive Tract, Veneto Institute of Oncology, Padua, Italy
| | - J Huddy
- Department Surgery and Cancer, Imperial College London, London, UK
| | - E Pinto
- Unit of Surgical Oncology of the Oesophagus and Digestive Tract, Veneto Institute of Oncology, Padua, Italy
| | - M Scarpa
- Unit of Surgical Oncology of the Oesophagus and Digestive Tract, Veneto Institute of Oncology, Padua, Italy
| | - F Klevebro
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - B Sunde
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - C F Murphy
- Department of Surgery, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - C Greene
- Department of Surgery, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - N Ravi
- Department of Surgery, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - G Piessen
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, F-59000 Lille, France
| | - H Brenkman
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - B P Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - M Pera
- Department of Surgery, University Hospital del Mar, Barcelona, Spain
| | - J Roigg
- Department of Surgery, University Hospital del Mar, Barcelona, Spain
| | - S Castro
- Department of Surgery, University Hospital del Mar, Barcelona, Spain
| | - R Matthijsen
- Department of Gastrointestinal Surgery, ETZ Tildburg, Tildburg, the Netherlands
| | - J Findlay
- Oesophago-gastric Centre, Churchill Hospital, University of Oxford, Oxford, UK
| | - S Antonowicz
- Oesophago-gastric Centre, Churchill Hospital, University of Oxford, Oxford, UK
| | - N Maynard
- Oesophago-gastric Centre, Churchill Hospital, University of Oxford, Oxford, UK
| | - O McCormack
- Department of Oesophago-Gastric Surgery, Royal Marsden Hospital, London, UK
| | - A Ariyarathenam
- Department of Oesophago-Gastric Surgery, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - G Sanders
- Department of Oesophago-Gastric Surgery, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - E Cheong
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich Hospitals NHS Trust, Norwich, UK
| | - S Jaunoo
- Department of Upper Gastrointestinal Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - W Allum
- Department of Oesophago-Gastric Surgery, Royal Marsden Hospital, London, UK
| | - J van Lanschot
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J V Reynolds
- Department of Surgery, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G B Hanna
- Department Surgery and Cancer, Imperial College London, London, UK
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37
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Linder G, Klevebro F, Edholm D, Johansson J, Lindblad M, Hedberg J. Burden of in-hospital care in oesophageal cancer: national population-based study. BJS Open 2021; 5:6271348. [PMID: 33960365 PMCID: PMC8103496 DOI: 10.1093/bjsopen/zrab037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/11/2021] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- G Linder
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - F Klevebro
- Department of Clinical Science, Intervention and Technology, Centre for Upper Gastrointestinal Cancer, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - D Edholm
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - J Johansson
- Department of Surgery, Lund University, Lund, Sweden
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Centre for Upper Gastrointestinal Cancer, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - J Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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38
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Boshier PR, Klevebro F, Jenq W, Puccetti F, Muthuswamy K, Hanna GB, Low DE. Long-term variation in skeletal muscle and adiposity in patients undergoing esophagectomy. Dis Esophagus 2021; 34:6209412. [PMID: 33822916 PMCID: PMC8597909 DOI: 10.1093/dote/doab016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 12/11/2022]
Abstract
This study seeks to define long-term variation in body composition in patients undergoing esophagectomy for cancer and to associate those changes with survival. Assessment of skeletal muscle, visceral (VAT) and subcutaneous adipose tissue (SAT) was performed using computed tomography (CT) images routinely acquired: at diagnosis; after neoadjuvant therapy, and; >6 months after esophagectomy. In cases where multiple CT scans were performed >6 months after surgery, all available images were assessed. Ninty-seven patients met inclusion criteria with a median of 2 (range 1-10) postoperative CT images acquired between 0.5 and 9.7 years after surgery. Following surgical treatment of esophageal cancer, patients lost on average 13.3% of their skeletal muscle, 64.5% of their VAT and 44.2% of their SAT. Sarcopenia at diagnosis was not associated with worse overall survival (66.3% vs. 68.5%; P = 0.331). Sarcopenia 1 year after esophagectomy was however associated with lower 5-year overall survival (53.8% vs. 87.5%; P = 0.019). Survival was lower in those patients who had >10% decrease in skeletal muscle index (SMI; 33.3% vs. 72.1%; P = 0.003) and >40% decrease in SAT 1 year after surgery (40.4% vs. 67.4%; P = 0.015). On multivariate analysis, a decline in SMI 1 year after surgery was predictive of worse survival (HR 0.38, 95%CI 0.20-0.73; P = 0.004). This study provides new insight relating to long-term variation in body composition in patients undergoing esophagectomy for cancer. Findings provide further evidence of the importance of body composition, in particular depletion of skeletal muscle, in predicting survival following esophagectomy.
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Affiliation(s)
- Piers R Boshier
- Address correspondence to: Mr Piers Boshier, Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Wing, St Mary’s Hospital, London W2 1NY, UK.
| | - Fredrik Klevebro
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Wesley Jenq
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Francesco Puccetti
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | | | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
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39
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Klevebro F, Johar A, Lagergren P. Reply to Comment on Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study by Li et al. Br J Surg 2021; 108:e208. [PMID: 33712832 DOI: 10.1093/bjs/znab042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 11/13/2022]
Affiliation(s)
- F Klevebro
- Surgical Care Science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - A Johar
- Surgical Care Science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - P Lagergren
- Surgical Care Science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
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40
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Holmén A, Hayami M, Szabo E, Rouvelas I, Agustsson T, Klevebro F. Nutritional jejunostomy in esophagectomy for cancer, a national register-based cohort study of associations with postoperative outcomes and survival. Langenbecks Arch Surg 2020; 406:1415-1423. [PMID: 33230577 PMCID: PMC8370925 DOI: 10.1007/s00423-020-02037-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/17/2020] [Indexed: 01/13/2023]
Abstract
Purpose Insertion of a nutritional jejunostomy in conjunction with esophagectomy is performed with the intention to decrease the risk for postoperative malnutrition and improve recovery without adding significant catheter-related complications. However, previous research has shown no clear benefit and there is currently no consensus of practice. Methods All patients treated with esophagectomy due to cancer during the period 2006–2017 reported in the Swedish National Register for Esophageal and Gastric Cancer were included in this register-based cohort study from a national database. Patients were stratified into two groups: esophagectomy alone and esophagectomy with jejunostomy. Results A total of 847 patients (45.27%) had no jejunostomy inserted while 1024 patients (54.73%) were treated with jejunostomy. The groups were comparable, but some differences were seen in histological tumor type and tumor stage between the groups. No significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate were seen. There was no evidence of increased risk for significant jejunostomy-related complications. Patients in the jejunostomy group with anastomotic leaks had a statistically significant lower risk for severe morbidity defined as Clavien-Dindo score ≥ IIIb (adjusted odds ratio 0.19, 95% CI: 0.04–0.94, P = 0.041) compared to patients with anastomotic leaks and no jejunostomy. Conclusion A nutritional jejunostomy is a safe method for early postoperative enteral nutrition which might decrease the risk for severe outcomes in patients with anastomotic leaks. Nutritional jejunostomy should be considered for patients undergoing curative intended surgery for esophageal and gastro-esophageal junction cancer.
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Affiliation(s)
- Anders Holmén
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Department of Surgery, Södersjukhuset, Stockholm, Sweden.
| | - Masaru Hayami
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Szabo
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Thorhallur Agustsson
- Department of Surgery, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet
- Södersjukhuset, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
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41
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Saliba G, Detlefsen S, Carneiro F, Conner J, Dorer R, Fléjou JF, Hahn H, Kamaradova K, Mastracci L, Meijer SL, Sabo E, Sheahan K, Riddell R, Wang N, Yantiss RK, Lundell L, Low D, Vieth M, Klevebro F. Tumor regression grading after neoadjuvant treatment of esophageal and gastroesophageal junction adenocarcinoma: results of an international Delphi consensus survey. Hum Pathol 2020; 108:60-67. [PMID: 33221343 DOI: 10.1016/j.humpath.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/08/2020] [Indexed: 12/21/2022]
Abstract
Complete histopathologic tumor regression after neoadjuvant treatment is a well-known prognostic factor for survival among patients with adenocarcinomas of the esophagus and gastroesophageal junction. The aim of this international Delphi survey was to reach a consensus regarding the most useful tumor regression grading (TRG) system that could represent an international standard for histopathologic TRG grading of gastroesophageal carcinomas. Fifteen pathologists with special interest in esophageal and gastric pathology participated in the online survey. The initial questionnaire contained of 43 statements that addressed the following topics: (1) specimen processing, (2) gross examination, (3) cross sectioning, (4) staining, (5) Barrett's esophagus, (6) TRG systems, and (7) TRG in lymph node (LN). Participants rated the items using a 5-point Likert style scale and were encouraged to write comments for each statement. The expert panel recommended a 4-tiered TRG system for assessing the primary tumor: grade 1: No residual tumor (complete histopathologic tumor regression), grade 2: less than 10% residual tumor (near-complete regression), grade 3: 10%-50% residual tumor (partial regression), grade 4: greater than 50% residual tumor (minimal/no regression), combined with a 3-tiered system for grading therapeutic response in metastatic LNs: grade a: no residual tumor (complete histopathologic TRG), grade b: partial regression (tumor cells and regression), grade c: no regression (no sign of tumor response). This TRG grading system can be recommended as an international standard for histopathologic TRG grading in esophageal and gastroesophageal junction adenocarcinoma.
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Affiliation(s)
- G Saliba
- Department of Upper Abdominal Surgery, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Karolinska Institutet, 141 57, Huddinge, Stockholm, Sweden.
| | - S Detlefsen
- Department of Pathology, Odense University Hospital, Denmark& Dept. of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, 5000, Odense, Denmark
| | - F Carneiro
- Centro Hospitalar Universitário de São João (CHUSJ)/Faculty of Medicine of the University of Porto (FMUP) and Instituto de Investigação e Inovação Em Saúde (i3S)/Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), 4200-319, Porto, Portugal
| | - J Conner
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, M5G 1X5, Toronto, Canada
| | - R Dorer
- Department of Pathology, Virginia Mason Medical Center, 98101, Seattle, WA, USA
| | - J F Fléjou
- Department of Pathology, Saint-Antoine Hospital, Pierre et Marie Curie University, 75571, Paris, France
| | - H Hahn
- Department of Pathology, Virginia Mason Medical Center, 98101, Seattle, WA, USA
| | - K Kamaradova
- The Fingerland Department of Pathology, Charles University Faculty of Medicine and University Hospital Hradec Králové, Hradec Králové, 500 03, Czech Republic
| | - L Mastracci
- Division of Anatomic Pathology, Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa and Ospedale Policlinico IRCCS San Martino, 16126, Genoa, Italy
| | - S L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Location AMC, 1081 HV, Amsterdam, the Netherlands
| | - E Sabo
- Department of Pathology, Carmel Medical Center, 3436212, Haifa, Israel
| | - K Sheahan
- Department of Pathology, St Vincent's University Hospital & UCD School of Medicine, Dublin, D04 T6F4, Ireland
| | - R Riddell
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, M5G 1X5, Toronto, Canada
| | - N Wang
- Department of Clinical Pathology, Karolinska University Hospital, Huddinge, 141 86, Stockolm, Sweden
| | - R K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, 10065, New York, NY, USA
| | - L Lundell
- Department of Upper Abdominal Surgery, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Karolinska Institutet, 141 57, Huddinge, Stockholm, Sweden; Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - M Vieth
- Institute of Pathology, Klinikum Bayreuth, 95445, Bayreuth, Germany
| | - F Klevebro
- Department of Upper Abdominal Surgery, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Karolinska Institutet, 141 57, Huddinge, Stockholm, Sweden
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42
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Nilsson K, Klevebro F, Rouvelas I, Lindblad M, Szabo E, Halldestam I, Smedh U, Wallner B, Johansson J, Johnsen G, Aahlin EK, Johannessen HO, Hjortland GO, Bartella I, Schröder W, Bruns C, Nilsson M. Surgical Morbidity and Mortality From the Multicenter Randomized Controlled NeoRes II Trial: Standard Versus Prolonged Time to Surgery After Neoadjuvant Chemoradiotherapy for Esophageal Cancer. Ann Surg 2020; 272:684-689. [PMID: 32833767 DOI: 10.1097/sla.0000000000004340] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate if prolonged TTS after completed nCRT improves postoperative outcomes for esophageal and esophagogastric junction cancer. SUMMARY OF BACKGROUND DATA TTS has traditionally been 4-6 weeks after completed nCRT. However, the optimal timing is not known. METHODS A multicenter clinical trial was performed with randomized allocation of TTS of 4-6 or 10-12 weeks. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality, and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101). RESULTS In total 249 patients were randomized. There were no significant differences between standard TTS and prolonged TTS with regard to overall incidence of complications Clavien-Dindo grade II-V (63.2% vs 72.6%, P = 0.134) or regarding Clavien-Dindo grade IIIb-V complications (31.6% vs 34.9%, P = 0.603). There were no statistically significant differences between standard and prolonged TTS regarding anastomotic leak (P = 0.596), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548), and respiratory failure (P = 0.723). In the standard TTS arm 5 patients (4.3%) died within 90 days of surgery, compared to 4 patients (3.8%) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.234). CONCLUSION The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction, is not of major importance with regard to short-term postoperative outcomes.
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Affiliation(s)
- Klara Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - Eva Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ingvar Halldestam
- Department of Surgery, University Hospital of Linköping, Linköping, Sweden
| | - Ulrika Smedh
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg Sweden
| | - Bengt Wallner
- Department of Surgical and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
| | - Jan Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Gjermund Johnsen
- Department of Gastrointestinal Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eirik Kjus Aahlin
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | - Isabel Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| | - Magnus Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden
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Klevebro F, Kuppusamy MK, Han S, Nikravan S, Neal JM, Strodtbeck W, Coy DL, Warren D, Hubka M, Hanson N, Low DE. Contrast-enhanced paravertebrogram to confirm paravertebral catheter position in elective thoracic surgery: a proof of concept study. Surg Endosc 2020; 35:6001-6005. [PMID: 33118060 PMCID: PMC8523414 DOI: 10.1007/s00464-020-08087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/03/2020] [Indexed: 12/05/2022]
Abstract
Background Paravertebral pain catheters have been shown to be equally effective as epidural pain catheters for postoperative analgesia after thoracic surgery with the possible additional benefit of less hemodynamic effect. However, a methodology for verifying correct paravertebral catheter placement has not been tested or objectively confirmed in previous studies. The aim of the current study was to describe a technique to confirm the correct position of a paravertebral pain catheter using a contrast-enhanced paravertebrogram. Methods A retrospective cohort proof of concept study was performed including 10 consecutive patients undergoing elective thoracic surgery with radiographic contrast-enhanced confirmation of intraoperative paravertebral catheter placement (paravertebrogram). Results The results of the paravertebrograms, which were done in the operating room at the end of the procedure, verified correct paravertebral catheter placement in 10 of 10 patients. The radiographs documented dissemination of local anesthetic within the paravertebral space. Conclusion This proof of concept study demonstrated that a contrast-enhanced paravertebrogram could be used in conjunction with standard postoperative chest radiography to add valuable information for the assessment of paravertebral catheter placement. This technique has the potential to increase the accuracy and efficiency of postoperative analgesia, and to set a quality standard for future studies of paravertebral pain catheters.
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Affiliation(s)
- Fredrik Klevebro
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA. .,CLINTEC, Karolinska Institutet, Stockholm, Sweden.
| | - Madhan Kumar Kuppusamy
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Shiwei Han
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Sara Nikravan
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA
| | - Wyndam Strodtbeck
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA
| | - David L Coy
- Department of Radiology, Virginia Mason Medical Center, Seattle, USA
| | - Daniel Warren
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA
| | - Michal Hubka
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Neil Hanson
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
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Tsekrekos A, Triantafyllou T, Klevebro F, Hayami M, Lindblad M, Nilsson M, Lundell L, Rouvelas I. Implementation of minimally invasive gastrectomy for gastric cancer in a western tertiary referral center. BMC Surg 2020; 20:157. [PMID: 32677942 PMCID: PMC7364615 DOI: 10.1186/s12893-020-00812-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/05/2020] [Indexed: 12/23/2022] Open
Abstract
Background Minimally invasive techniques have gradually come to take a leading position in the surgical treatment of gastrointestinal malignancies. In order to define an effective process for the implementation of similar techniques in the treatment of gastric cancer, patient caseload represents a pivotal factor for education and training, but is a prerequisite not fulfilled in most Western countries. Additionally, as opposed to the East, a variety of additional factors such as the usually advanced stage of the disease and differences in patient characteristics are prevailing and raise further obstacles. Hereby we report a strategy for a safe and effective process for the implementation of laparoscopic gastric cancer surgery in a Western tertiary referral center. Methods The present study describes the stepwise implementation of laparoscopic gastrectomy for the treatment of gastric cancer at a tertiary referral center, comprising the time period 2012–2019. This process was facilitated by a close collaboration with two high-volume centers in Japan, as well as exchanging fellowships and observerships between the Karolinska University Hospital and other European centers. From the initially strict selection of cases for laparoscopic surgery, laparoscopic gastrectomy has gradually become the preferred approach also in patients with locally advanced tumors. Results From January 1st 2010 until December 31st 2019, 249 patients were operated for gastric cancer, of whom 141 (56.6%) had an open and 108 (43.4%) a laparoscopic procedure. In the latter group, total gastrectomy was performed in 33.3% of the patients. While blood loss, operation time and length of stay decreased during the first years after implementation, these variables increased slightly during the last years of the study period, probably due to the higher proportion of advanced gastric cancer cases, as well as the higher rate of laparoscopic total gastrectomy with more extended lymphadenectomy. Conclusions Laparoscopic surgery is currently a valid therapeutic option for gastric cancer, which has expanded to also embrace total gastrectomy and locally advanced tumors. Collaboration between centers in the East and West, centralization to high-volume centers and application of enhanced recovery protocols are essential components in the implementation and further refinement of minimally invasive gastrectomy.
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Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Tania Triantafyllou
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,1st Propaedeutic Surgical Clinic, Hippocration General Hospital, Athens, Greece
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Masaru Hayami
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden. .,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
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45
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Saliba G, Hayami M, Klevebro F, Nilsson M. Surgical treatment of Siewert type II gastroesophageal junction cancer: esophagectomy, total gastrectomy or other options? ACTA ACUST UNITED AC 2020. [DOI: 10.21037/aoe-2020-geja-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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46
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Ericson J, Lundell L, Lindblad M, Klevebro F, Nilsson M, Rouvelas I. Assessment of energy intake and total energy expenditure in a series of patients who have undergone oesophagectomy following neoadjuvant treatment. Clin Nutr ESPEN 2020; 37:121-128. [DOI: 10.1016/j.clnesp.2020.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 02/09/2023]
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47
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Klevebro F, Johar A, Lagergren P. Impact of co-morbidities on health-related quality of life 10 years after surgical treatment of oesophageal cancer. BJS Open 2020; 4:601-604. [PMID: 32472656 PMCID: PMC7397362 DOI: 10.1002/bjs5.50303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/04/2020] [Indexed: 11/14/2022] Open
Abstract
Background Oesophagectomy for cancer is associated with long‐term decreased health‐related quality of life (HRQoL). The aim of this study was to evaluate the effect of co‐morbidities on HRQoL among survivors of oesophageal or gastro‐oesophageal junctional cancers after 10 years or
more. Methods The study included a prospectively collected, population‐based cohort, comprising all patients who had surgery for oesophageal or gastro‐oesophageal junctional cancer in Sweden in 2001–2005 with follow‐up until 31 December 2016. All data regarding patient and tumour characteristics, treatment details and HRQoL were collected using a prospectively created database. Multivariable ANCOVA regression models, adjusting for age, sex, tumour histology, stage and surgical technique, were used to calculate adjusted mean scores with 95 per cent confidence intervals for all HRQoL outcomes. Results A total of 92 survivors (88·5 per cent) responded to the questionnaires. Patients were stratified in two groups according to whether they reported a low or high impact of co‐morbidities on general health. Patients in the high‐impact group had clinically significantly decreased HRQoL and an increased level of symptoms, but differences between these two groups were not statistically significant. Conclusion Co‐morbidities with high impact on general health still contribute to impaired HRQoL 10 years after oesophagectomy for cancer.
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Affiliation(s)
- F Klevebro
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Johar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Surgery and Cancer, Imperial College London, London, UK
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48
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Klevebro F, Tsekrekos A, Low D, Lundell L, Vieth M, Detlefsen S. Relevant issues in tumor regression grading of histopathological response to neoadjuvant treatment in adenocarcinomas of the esophagus and gastroesophageal junction. Dis Esophagus 2020; 33:5788233. [PMID: 32141500 PMCID: PMC7273185 DOI: 10.1093/dote/doaa005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/22/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
Multimodality treatment combining surgery and oncologic treatment has become widely applied in curative treatment of esophageal and gastroesophageal junction adenocarcinoma. There is a need for a standardized tumor regression grade scoring system for clinically relevant effects of neoadjuvant treatment effects. There are numerous tumor regression grading systems in use and there is no international standardization. This review has found nine different international systems currently in use. These systems all differ in detail, which inhibits valid comparisons of results between studies. Tumor regression grading in esophageal and gastroesophageal junction adenocarcinoma needs to be improved and standardized. To achieve this goal, we have invited a significant group of international esophageal and gastroesophageal junction adenocarcinoma pathology experts to perform a structured review in the form of a Delphi process. The aims of the Delphi include specifying the details for the disposal of the surgical specimen and defining the details of, and the reporting from, the agreed histological tumor regression grade system including resected lymph nodes. The second step will be to perform a validation study of the agreed tumor regression grading system to ensure a scientifically robust inter- and intra-observer variability and to incorporate the consented tumor regression grading system in clinical studies to assess its predictive and prognostic role in treatment of esophageal and gastroesophageal junction adenocarcinomas. The ultimate aim of the project is to improve survival in esophageal and gastroesophageal adenocarcinoma by increasing the quality of tumor regression grading, which is a key component in treatment evaluation and future studies of individualized treatment of esophageal cancer.
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Affiliation(s)
- F Klevebro
- Department of Upper Abdominal Surgery, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - A Tsekrekos
- Department of Upper Abdominal Surgery, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - L Lundell
- Department of Upper Abdominal Surgery, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - M Vieth
- Institute of Pathology, Bayreuth, Germany
| | - S Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark
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49
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Wirsching A, Klevebro F, Boshier PR, Hubka M, Kuppusamy MK, Kirtland SH, Low DE. The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function. Dis Esophagus 2019; 32:doz032. [PMID: 31220858 DOI: 10.1093/dote/doz032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/13/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.
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Affiliation(s)
| | | | | | | | | | - Steve H Kirtland
- Department of Pulmonary Medicine, Virginia Mason Medical Center, Seattle, USA
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50
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Tsekrekos A, Klevebro F, Hayami M, Kamiya S, Lindblad M, Nilsson M, Lundell L, Rouvelas I. Laparoscopic Versus Open Gastrectomy for Cancer: A Western Center Cohort Study. J Surg Res 2019; 247:372-379. [PMID: 31679797 DOI: 10.1016/j.jss.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic gastrectomy (LG) for cancer has been introduced in institutions worldwide in an effort to minimize surgical trauma, while aiming to provide comparable oncological outcomes to conventional open gastrectomy (OG). The aim of this study was to present our results during the period of implementation of the laparoscopic technique. MATERIALS AND METHODS In 2012, LG for the treatment of gastric cancer was introduced at our institution. The results presented are based on a retrospective analysis of data from a cohort of all patients treated with curative intent over the period 2010-2018. RESULTS During the study period, 206 patients underwent surgery for gastric cancer: 129 patients (62.6%) had an OG and 77 patients (37.4%) an LG. The conversion rate due to technical reasons was 2.6%. LG was associated with significantly less intraoperative blood loss [mean (mL), OG 544 versus LG 176] and shorter hospital stay than OG [mean (d), OG 12 versus LG 8], fewer severe complications (Clavien-Dindo grade ≥ IIIb) [OG 29 (22.5%) versus LG 9 (11.7%), P = 0.081], significantly lower anastomotic leak rate [OG 18 (14.0%) versus LG 1 (1.3%)] and no 90-day mortality. The percentage of R0 resections was similar between the two groups (OG 82.2% versus LG 85.7%, P = 0.507), while the mean number of resected lymph nodes was significantly higher in the laparoscopic group [OG 34 versus LG 39, P = 0.030]. CONCLUSIONS Our data suggest that similar and, in some aspects, better short-term outcomes can be achieved with LG with maintained oncological quality.
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Affiliation(s)
- Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Masaru Hayami
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Satoshi Kamiya
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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