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Sahm E, Olutola O, Ata A, Fabian T, Marthy A, Deroo A, Edwards K, Tafen M. When Is Intensive Care Unit Admission Needed After an Esophagectomy? J Surg Res 2024; 300:109-116. [PMID: 38810525 DOI: 10.1016/j.jss.2024.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Due to the high morbidity associated with esophagectomies, patients are often directly admitted to intensive care units (ICUs) for postoperative monitoring. However, critical complications can arise after this initial ICU stay. We hypothesized that the timing of ICU stay was not optimal for the care of patients after esophagectomy and aimed to determine when patients are at risk for developing critical complications. METHODS We searched the National Safety and Quality Improvement Program for patients who underwent an esophagectomy between 2016 and 2021. The outcome of interest was the interval between surgery and first critical complication. A critical complication was defined as one likely to require intensive care, including respiratory failure, septic shock, etc. Multivariate regression was performed to identify the risks of complications. RESULTS This study included 6813 patients from more than 70 institutions. Within the first 30 d postesophagectomy, 21.59% of patients experienced at least one critical complication. Half of first critical complications occurred after postoperative day 5, and 85.05% of them occurred after postoperative day 2. Risk factors for critical complications included age greater than 60 y, preoperative comorbidities, and open surgical approach. Malignancies were associated with a significantly lower incidence of critical complications. CONCLUSIONS Critical complications occurred beyond the immediate postesophagectomy period. Therefore, low-risk patients undergoing minimally invasive esophagectomies can be safely monitored outside the ICU, allowing for better patient care and resource utilization.
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Affiliation(s)
- Erin Sahm
- Albany Medical College, Albany, New York.
| | - Olatoye Olutola
- Division of Trauma, Critical Care, and Acute Care Surgery, Case Western Reserve, Cleveland, Ohio; Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Ashar Ata
- Department of Surgery, Albany Medical Center, Albany, New York
| | - Thomas Fabian
- Division of Thoracic Surgery, Albany Medical Center, Albany, New York
| | - Andrew Marthy
- Division of Thoracic Surgery, Albany Medical Center, Albany, New York
| | - Andrew Deroo
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Kurt Edwards
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Marcel Tafen
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
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Bollschweiler E, Hölscher AH, Markar SR, Alakus H, Drebber U, Mönig SP, Plum PS. Premature mortality for patients after completely resected early adenocarcinoma of the esophagus or stomach. Cancer Med 2024; 13:e7223. [PMID: 38778711 PMCID: PMC11112294 DOI: 10.1002/cam4.7223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/14/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE To establish the life expectancy burden of esophago-gastric cancer by analyzing years of life lost (YLL) for a Western patient population after treatment of early esophageal (EAC) or early gastric (GAC) adenocarcinoma. BACKGROUND For patients with early EAC or GAC, the short-term prognosis after surgical resection is very good. Little data is available regarding long-term prognosis when compared to the general population. METHODS Two hundred and fourteen patients with pT1 EAC (n = 112) or GAC (n = 102) were included in the study. Patients with EAC underwent transthoracic en-bloc esophagectomy; those with GAC had total or subtotal gastrectomy with D2-lymphadenectomy. Surviving patients had a median follow-up of approximately 14 years. YLL was calculated using average life expectancy data from Germany. RESULTS Patients with EAC were younger (median age 61 years) than those with GAC (66 years) (p = 0.031). The male:female ratio was 10:1 for EAC and 3:2 for GAC (p < 0.001). Multivariate survival analysis showed the age of the patients ≥60 years and the existence of lymph node metastasis was associated with poor prognosis. The median YLL for all patients who died over follow-up was 8.0 years. For patients under 60 years, it was approximately 20 years, and for older patients, approximately 5 years (p < 0.001) without difference in tumor stage between these age cohorts. YLL did not differ for GAC vs. EAC. CONCLUSION After surgical resection, the prognostic burden as measured by YLL is relevant for all patients with early esophageal and gastric adenocarcinomas and especially for younger patients. Reasons for YLL need further studies.
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Affiliation(s)
| | | | - Sheraz R. Markar
- Surgical Interventional Trials Unit, Nuffield Department of SurgeryUniversity of OxfordOxfordUK
| | - Hakan Alakus
- Department of General, Visceral and Cancer SurgeryUniversity of CologneCologneGermany
| | - Uta Drebber
- Institute of Pathology, University of CologneCologneGermany
| | - Stefan Paul Mönig
- Department of Visceral SurgeryGeneva University HospitalsGenevaSwitzerland
| | - Patrick Sven Plum
- Department of Visceral, Transplantation, Thoracic and Vascular SurgeryUniversity Hospital of LeipzigLeipzigGermany
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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Fujita T, Sato K, Fujiwara N, Kajiyama D, Shigeno T, Daiko H. A novel imaging technology to assess tissue oxygen saturation and its correlation with indocyanine green in the gastric conduit during thoracic esophagectomy. Surgery 2024; 175:360-367. [PMID: 38001012 DOI: 10.1016/j.surg.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/17/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Anastomotic leakage in esophagectomy is a serious complication, and assessing blood perfusion in the conduit can help minimize this risk. Indocyanine green is the most widely used method to assess tissue blood flow; however, this technique has disadvantages. Evaluating tissue oxygen saturation in the gastric conduit during thoracic esophagectomy compared with indocyanine green blood perfusion assessment addresses these disadvantages and can be performed easily and repeatedly. METHODS This was a prospective study of patients with esophageal cancer who underwent thoracic esophagectomy. Intraoperative tissue oxygen saturation and indocyanine green measurements were obtained to determine the anastomotic site and to compare the correlation between the 2 methods. Tissue oxygen saturation and indocyanine green values were obtained at the tip of the gastric conduit, the demarcation line indicating visible perfusion, and the end of the right gastroepiploic artery. RESULTS Fifty-seven patients were enrolled in this study; 3 developed anastomotic leakage, and all 3 underwent robotic thoracic surgery. The tissue oxygen saturation value decreased gradually toward the tip of the conduit, as did congestion, and was significantly decreased at the tip compared with the value at the demarcation line (P = .001). Mean tissue oxygen saturation differed significantly between the leakage and no-leakage groups at the anastomosis site (P = .04). We found a negative correlation between tissue oxygen saturation and indocyanine green values at the end of the right gastroepiploic artery (r = -0.361; P = .03). CONCLUSION Tissue oxygen saturation imaging was useful in determining the anastomotic site and addressed the disadvantages associated with indocyanine green.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan.
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Naoto Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Daisuke Kajiyama
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takashi Shigeno
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
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Fujita T, Shigeno T, Kajiyama D, Sato K, Fujiwara N, Daiko H. A novel device to assess the oxygen saturation and congestion status of the gastric conduit in thoracic esophagectomy. BMC Surg 2024; 24:17. [PMID: 38191379 PMCID: PMC10775575 DOI: 10.1186/s12893-023-02303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND In thoracic esophagectomy, anastomotic leakage is one of the most important surgical complications. Indocyanine green (ICG) is the most widely used method to assess tissue blood flow; however, this technique has been pointed out to have disadvantages such as difficulty in evaluating the degree of congestion, lack of objectivity in evaluating the degree of staining, and bias easily caused by ICG injection, camera distance, and other factors. Evaluating tissue oxygen saturation (StO2) overcomes these disadvantages and can be performed easily and repeatedly. It is also possible to measure objective values including the degree of congestion. We evaluate novel imaging technology to assess tissue oxygen saturation (StO2) in the gastric conduit during thoracic esophagectomy. METHODS Fifty patients were enrolled, with seven excluded due to intraoperative findings, leaving 43 for analysis. These patients underwent thoracic esophagectomy for esophageal cancer. The device was used intraoperatively to evaluate tissue oxygen saturation (StO2) and total hemoglobin index (T-HbI), which guided the optimal site for gastric tube anastomosis. The efficacies of StO2 and T-HbI in relation to short-term outcomes were analyzed. RESULTS StO2, indicating blood supply to the gastric tube, remained stable beyond the right gastroepiploic artery (RGEA) end but significantly decreased distally to the demarcation line (p < 0.05). T-HbI, indicative of congestion, significantly decreased past the RGEA (p < 0.05). Three patients experienced anastomotic leakage. These patients exhibited significantly lower StO2 (p < 0.01) and higher T-HbI (p < 0.01) at both the RGEA end and the demarcation line. Furthermore, the anastomotic site, usually within 3 cm of the RGEA's anorectal side, also showed significantly lower StO2 (p < 0.01) and higher T-HbI (p < 0.01) in patients with anastomotic leakage. CONCLUSIONS The novel device provides real-time, objective evaluations of blood flow and congestion in the gastric tube. It proves useful for safer reconstruction during thoracic esophagectomy, particularly by identifying optimal anastomosis sites and predicting potential anastomotic leakage.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Takashi Shigeno
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Daisuke Kajiyama
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Naoto Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Jung JO, Pisula JI, Bozek K, Popp F, Fuchs HF, Schröder W, Bruns CJ, Schmidt T. Prediction of postoperative complications after oesophagectomy using machine-learning methods. Br J Surg 2023; 110:1361-1366. [PMID: 37343072 DOI: 10.1093/bjs/znad181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/17/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Oesophagectomy is an operation with a high risk of postoperative complications. The aim of this single-centre retrospective study was to apply machine-learning methods to predict complications (Clavien-Dindo grade IIIa or higher) and specific adverse events. METHODS Patients with resectable adenocarcinoma or squamous cell carcinoma of the oesophagus and gastro-oesophageal junction who underwent Ivor Lewis oesophagectomy between 2016 and 2021 were included. The tested algorithms were logistic regression after recursive feature elimination, random forest, k-nearest neighbour, support vector machine, and neural network. The algorithms were also compared with a current risk score (the Cologne risk score). RESULTS 457 patients had Clavien-Dindo grade IIIa or higher complications (52.9 per cent) versus 407 patients with Clavien-Dindo grade 0, I, or II complications (47.1 per cent). After 3-fold imputation and 3-fold cross-validation, the overall accuracies were: logistic regression after recursive feature elimination, 0.528; random forest, 0.535; k-nearest neighbour, 0.491; support vector machine, 0.511; neural network, 0.688; and Cologne risk score, 0.510. For medical complications, the results were: logistic regression after recursive feature elimination, 0.688; random forest, 0.664; k-nearest neighbour, 0.673; support vector machine, 0.681; neural network, 0.692; and Cologne risk score, 0.650. For surgical complications, the results were: logistic regression after recursive feature elimination, 0.621; random forest, 0.617; k-nearest neighbour, 0.620; support vector machine, 0.634; neural network, 0.667; and Cologne risk score, 0.624. The calculated area under the curve of the neural network was 0.672 for Clavien-Dindo grade IIIa or higher, 0.695 for medical complications, and 0.653 for surgical complications. CONCLUSION The neural network scored the highest accuracies compared with all of the other models for the prediction of postoperative complications after oesophagectomy.
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Affiliation(s)
- Jin-On Jung
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Juan I Pisula
- Centre for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Kasia Bozek
- Centre for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Felix Popp
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Tumour, and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
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Hagens ERC, Cui N, van Dieren S, Eshuis WJ, Laméris W, van Berge Henegouwen MI, Gisbertz SS. Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon. Ann Surg Oncol 2023; 30:5159-5169. [PMID: 37120485 PMCID: PMC10319689 DOI: 10.1245/s10434-023-13473-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 03/21/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models. METHODS Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes. RESULTS Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models. CONCLUSION Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.
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Affiliation(s)
- Eliza R C Hagens
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Nanke Cui
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Wytze Laméris
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands.
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Böhme F, Racz K, Sebesta C, Sebesta C. [Esophageal Cancer]. Wien Med Wochenschr 2023; 173:209-215. [PMID: 36318394 DOI: 10.1007/s10354-022-00972-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 09/05/2022] [Indexed: 05/31/2023]
Abstract
Esophageal cancer has poor prognosis and high letality. With yearly 600,000 new cases worldwide it ist he sixt most common cancer worldwide and the eight most deadly. Squamous cell carcinoma is more common in Africa and Asia, whereas incidence of adenocarcinoma ist increasing in Norh America and Europe. Riskfactors include alcohol, smoking, obesity, esophageal stenosis or achalasia. Currently there are no recommendations for prevention strategies or cancer screening. Symptoms in early stages are unspecific, so diagnosis is made late. Diagnostics include gastroscopy, CT, PET and endosonography. Therapeutic approaches are depending on disease stage and patients general condition. In early stages endoscopic resection is the treatment of choice. In higher stages theraoy consists of surgical resection and radiochemotherapy. Generalised stade ist treated with palliative systemic therapy and local interventions.
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Affiliation(s)
- Felix Böhme
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich.
| | - Krisztina Racz
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
| | - Christian Sebesta
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
| | - Christian Sebesta
- 2. Medizinische Abteilung, Klinik Donaustadt, Langobardenstraße 122, 1220, Wien, Österreich
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Grantham JP, Hii A, Shenfine J. Preoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:450-470. [PMID: 37032794 PMCID: PMC10080602 DOI: 10.4240/wjgs.v15.i3.450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 02/23/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making.
AIM To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.
METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness.
RESULTS The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness.
CONCLUSION Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Adelaide 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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Fujita T, Sato K, Ozaki A, Tomohiro A, Sato T, Hirano Y, Fujiwara H, Yoda Y, Kojima T, Yano T, Daiko H. A novel imaging technology to assess oxygen saturation of the gastric conduit in thoracic esophagectomy. Surg Endosc 2022; 36:7597-7606. [PMID: 35364701 DOI: 10.1007/s00464-022-09199-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Real-time evaluation of blood perfusion is important when selecting the site of anastomosis during thoracic esophagectomy. This study investigated a novel imaging technology that assesses tissue oxygen saturation (StO2) in the gastric conduit and examined its efficacy. METHODS Fifty-one patients undergoing thoracic esophagectomy for esophageal cancer who underwent intraoperative StO2 endoscopic imaging to assess the gastric conduit for the optimal site of anastomosis were examined. Efficacy of oxygen saturation imaging and patient outcomes were analyzed. RESULTS All 51 patients underwent esophagectomy without intraoperative problems. Mean StO2 in the gastric tube was highest at the pre-pylorus area and then gradually decreased proceeding toward the tip. StO2 was well preserved in areas supplied by the right gastroepiploic artery but low in other areas. Anastomotic sites were selected based on StO2 imaging and tension considerations; most were located within 3 cm of the end of the right gastroepiploic artery. Three patients developed postoperative anastomotic leakage (5.8%). Mean StO2 at the point of anastomosis was significantly lower in the patients who experienced leakage than in those who did not (P = 0.04). CONCLUSION Intraoperative endoscopic StO2 imaging is useful in esophageal cancer patients undergoing thoracic esophagectomy to determine the optimal site for anastomosis to minimize the risk of anastomotic leakage.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Asasko Ozaki
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Akutsu Tomohiro
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takuji Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuki Hirano
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hisashi Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yusuke Yoda
- Division of Gastrointestinal Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takashi Kojima
- Division of Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomonori Yano
- Division of Gastrointestinal Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
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12
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Harriott CB, Angeramo CA, Casas MA, Schlottmann F. Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis. J Thorac Cardiovasc Surg 2022; 164:e233-e254. [DOI: 10.1016/j.jtcvs.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
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13
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Hagens ERC, Reijntjes MA, Anderegg MCJ, Eshuis WJ, van Berge Henegouwen MI, Gisbertz SS. Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer. Ann Thorac Surg 2021; 112:255-263. [PMID: 33075324 DOI: 10.1016/j.athoracsur.2020.08.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/05/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Identifying predictors of anastomotic leakage can contribute to prevention of this common complication after esophagectomy. This study identified predictors for anastomotic leakage and assessed the influence of anastomotic leakage on short-term outcomes and long-term survival. METHODS A retrospective cohort study was conducted of consecutive patients who underwent esophagectomy in the Amsterdam University Medical Centers, location Amsterdam Medical Center, between 1993 and 2019. Multilevel logistic and Cox regression models were used to assess predictors for anastomotic leakage and survival, and an operation year-level random effects was considered for the unmeasured characteristics at year of operation. RESULTS Included were 1539 patients, and anastomotic leakage developed in 288 (19%). Predictors for developing anastomotic leakage after a transthoracic esophagectomy were a higher body mass index and a cervical anastomosis. Diabetes mellitus type 2 and chronic obstructive pulmonary disease were predictors for anastomotic leakage after a transhiatal esophagectomy. Median intensive care unit and hospital stay was longer for patients with anastomotic leakage than for patients without anastomotic leakage (both P < .001 for transthoracic esophagectomy, P = .010 and P < .001, respectively, for transhiatal esophagectomy). A higher percentage of patients with anastomotic leakage died within 30 days (3.8% vs 1.9%, P = .050). However, anastomotic leakage did not significantly influence long-term survival (hazard ratio, 0.994; 95% CI, 0.849-1.176; P = .994). CONCLUSIONS Higher body mass index, cervical anastomosis, diabetes mellitus, and chronic obstructive pulmonary disease are predictors for anastomotic leakage after esophagectomy. Anastomotic leakage is associated with worse short-term outcomes, but long-term survival was not influenced. Future studies should focus on patient optimization, accurate patient selection, and development of tools in risk assessment.
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Affiliation(s)
- Eliza R C Hagens
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands
| | - Maud A Reijntjes
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands
| | - Martinus C J Anderegg
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, location Amsterdam Medical Center, University of Amsterdam Cancer Center, Amsterdam, the Netherlands.
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14
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Fehrenbach U, Wuensch T, Gabriel P, Segger L, Yamaguchi T, Auer TA, Beetz NL, Denecke C, Kröll D, Raakow J, Knitter S, Chopra S, Thuss-Patience P, Pratschke J, Hamm B, Biebl M, Geisel D. CT Body Composition of Sarcopenia and Sarcopenic Obesity: Predictors of Postoperative Complications and Survival in Patients with Locally Advanced Esophageal Adenocarcinoma. Cancers (Basel) 2021; 13:cancers13122921. [PMID: 34208070 PMCID: PMC8230687 DOI: 10.3390/cancers13122921] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND To assess the impact of body composition imaging biomarkers in computed tomography (CT) on the perioperative morbidity and survival after surgery of patients with esophageal cancer (EC). METHODS Eighty-five patients who underwent esophagectomy for locally advanced EC after neoadjuvant therapy between 2014 and 2019 were retrospectively enrolled. Pre- and postoperative CT scans were used to assess the body composition imaging biomarkers (visceral (VAT) and subcutaneous adipose tissue (SAT) areas, psoas muscle area (PMA) and volume (PMV), total abdominal muscle area (TAMA)). Sarcopenia was defined as lumbar skeletal muscle index (LSMI) ≤38.5 cm2/m2 in women and ≤52.4 cm2/m2 in men. Patients with a body mass index (BMI) of ≥30 were considered obese. These imaging biomarkers were correlated with major complications, anastomotic leakage, postoperative pneumonia, duration of postoperative hospitalization, disease-free survival (DFS), and overall survival (OS). RESULTS Preoperatively, sarcopenia was identified in 58 patients (68.2%), and sarcopenic obesity was present in 7 patients (8.2%). Sarcopenic patients were found to have an elevated risk for the occurrence of major complications (OR: 2.587, p = 0.048) and prolonged hospitalization (32 d vs. 19 d, p = 0.040). Patients with sarcopenic obesity had a significantly higher risk for postoperative pneumonia (OR: 6.364 p = 0.018) and a longer postoperative hospital stay (71 d vs. 24 d, p = 0.021). Neither sarcopenia nor sarcopenic obesity was an independent risk factor for the occurrence of anastomotic leakage (p > 0.05). Low preoperative muscle biomarkers (PMA and PMV) and their decrease (ΔPMV and ΔTAMA) during the follow-up period significantly correlated with shorter DFS and OS (p = 0.005 to 0.048). CONCLUSION CT body composition imaging biomarkers can identify high-risk patients with locally advanced esophageal cancer undergoing surgery. Sarcopenic patients have a higher risk of major complications, and patients with sarcopenic obesity are more prone to postoperative pneumonia. Sarcopenia and sarcopenic obesity are both subsequently associated with a prolonged hospitalization. Low preoperative muscle mass and its decrease during the postoperative follow-up are associated with lower DFS and OS.
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Affiliation(s)
- Uli Fehrenbach
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
- Correspondence: ; Tel.: +49-(0)30-450-557-001; Fax: +49-(0)30-450-755-7901
| | - Tilo Wuensch
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Pia Gabriel
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Laura Segger
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Takeru Yamaguchi
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe 6500017, Japan;
| | - Timo Alexander Auer
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Nick Lasse Beetz
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Christian Denecke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Dino Kröll
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Jonas Raakow
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Sebastian Knitter
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Sascha Chopra
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Peter Thuss-Patience
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Dominik Geisel
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
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15
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Cuijpers ACM, Coolsen MME, Schnabel RM, van Santen S, Olde Damink SWM, van de Poll MCG. Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery. World J Surg 2020; 44:4060-4069. [PMID: 32864720 PMCID: PMC7599195 DOI: 10.1007/s00268-020-05742-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 12/25/2022]
Abstract
Background Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU). Methods A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission. Results In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively). Conclusions Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.
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Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands. .,Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Marielle M E Coolsen
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Susanne van Santen
- Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
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16
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Eichelmann AK, Saidi M, Lindner K, Lenschow C, Palmes D, Pascher A, Hummel R. Impact of preoperative risk factors on outcome after gastrectomy. World J Surg Oncol 2020; 18:17. [PMID: 31980026 PMCID: PMC6982377 DOI: 10.1186/s12957-020-1790-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background Gastrectomy is associated with relevant postoperative morbidity. However, outcome of surgery can be improved by careful selection of patients. The objective of the current study was therefore to identify preoperative risk factors that might impact on patients’ further outcome after surgical resection. Methods Preoperative risk factors having respectively different surgical risk scores for major complex surgery (including Cologne Risk Score, p-/o-POSSUM, and NSQIP risk score) of patients that underwent gastrectomy for AEG II/III tumors and gastric cancer were correlated with complications according to Clavien-Dindo and outcome. Patients who underwent surgery in palliative intention were excluded from further analysis. Results Subtotal gastrectomy was performed in 23%, gastrectomy in 59%, and extended gastrectomy in 18% in a total of 139 patients (mean age: 64 years old). Thirty six percent experienced a minor complication (Dindo I-II) and 24% a major complication (Dindo III-V), which resulted in a prolonged hospital stay (p < 0.001). In-hospital mortality (=Dindo V) was 2.5%. Besides age, type of surgical procedure impacted on complications with extended gastrectomy showing the highest risk (p = 0.005). The o-POSSUM score failed to predict mortality accurately. We observed a highly positive correlation between predicted morbidity respectively mortality and occurrence of complications estimated by p-POSSUM (p = 0.005), Cologne Risk (p = 0.007), and NSQIP scores (p < 0.001). Conclusion The results demonstrate a significant association between different risk scores and occurrence of complications following gastrectomy. The p-POSSUM, Cologne Risk, and NSQIP score exhibited superior performance than the o-POSSUM score. Therefore, these scores might allow identification and selection of high-risk patients and thus might be highly useful for clinical decision making.
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Affiliation(s)
- Ann-Kathrin Eichelmann
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, W1, 48149, Münster, Germany.
| | - Meltem Saidi
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, W1, 48149, Münster, Germany
| | - Kirsten Lindner
- Department of Surgery, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christina Lenschow
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Daniel Palmes
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, W1, 48149, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, W1, 48149, Münster, Germany
| | - Richard Hummel
- Department of Surgery, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
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17
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Prätherapeutische Fehlklassifikationen bei Ösophaguskarzinomen und Adenokarzinomen des ösophagogastralen Übergangs. Chirurg 2020; 91:41-50. [DOI: 10.1007/s00104-019-1011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Fuchs HF, Müller DT, Leers JM, Schröder W, Bruns CJ. Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center. Transl Gastroenterol Hepatol 2019; 4:62. [PMID: 31559343 DOI: 10.21037/tgh.2019.07.04] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/11/2019] [Indexed: 01/26/2023] Open
Abstract
Background The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery. Methods A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy. Results A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case. Conclusions The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Dolores T Müller
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Jessica M Leers
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
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19
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Goense L, Meziani J, Bülbül M, Braithwaite SA, van Hillegersberg R, Ruurda JP. Pulmonary diffusion capacity predicts major complications after esophagectomy for patients with esophageal cancer. Dis Esophagus 2019; 32:5098586. [PMID: 30239639 DOI: 10.1093/dote/doy082] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/16/2018] [Accepted: 08/09/2018] [Indexed: 12/11/2022]
Abstract
A reduced forced expiratory volume in one second (FEV1) is a well-recognized risk factor for complications after esophagectomy. Lung diffusing capacity for carbon monoxide (DLCO) is not routinely integrated in the risk assessment of esophagectomy. The aim of this study is to evaluate the association of preoperative pulmonary function tests with major postoperative complications after esophagectomy for cancer. In order to achieve this aim, 459 patients with newly diagnosed esophageal cancer who underwent elective transthoracic (n = 352) or transhiatal (n = 107) surgical resection of the esophagus with cervical anastomosis between 2003 and 2015 were analyzed. Multivariable logistic regression analysis was performed to assess the association of preoperative pulmonary function tests (expressed as % of predicted) with major complications after esophagectomy, adjusted for previously identified predictors. Major complications were defined as Clavien-Dindo grade IIIb or higher. Of the 459 included patients, 114 (24.8%) developed major complications. In univariable analysis FEV1, forced vital capacity (FVC), vital capacity (VC), and DLCO were associated with major complications. After adjusting each pulmonary function test for age, American Society of Anesthesiologists (ASA) score, cardiac comorbidity, diabetes mellitus, peripheral vascular disease, and surgical approach, FVC (OR: 1.24 per 10% decrease; 95% CI: 1.06-1.45; P = 0.004), VC (OR: 1.19 per 10% decrease; 95% CI: 1.02-1.39; P = 0.025) and DLCO (OR: 1.16 per 10% decrease; 95%CI: 1.02-1.33; P = 0.025) remained predictive factors for major surgical complications. In multivariable analysis in which all pulmonary functions tests were combined, DLCO was the strongest predictor of major complications (OR: 1.14 per 10% increase; 95% CI: 1.01-1.30; P = 0.046). The ideal cut-off for DLCO% of predicted was determined at <84% (OR: 1.97; 95% CI: 1.28-3.03; P = 0.002). These data indicate that DLCO is an independent predictor of major complications after esophagectomy for cancer. This pulmonary function test deserves greater consideration in prediction research of major complications after esophagectomy.
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Affiliation(s)
- L Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - J Meziani
- Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - M Bülbül
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - S A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
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20
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Abstract
The current German S3 guideline represents the recommendations for the diagnosis and therapy of squamous cell carcinomas and adenocarcinomas of the esophagus based on evidence from the literature and interdisciplinary expert consensus. Esophagogastroscopy with biopsy, endosonography, and spiral CT scan of the neck, thorax, and abdomen are decisive in staging and the choice of therapy. For a curative approach, surgery, especially transthoracic esophagectomy and gastric pull-up, is the most important therapeutic option, except in the case of mucosal carcinomas or cervical squamous cell carcinomas. The significance of total minimally invasive esophageal resection or a hybrid technique is still uncertain. In category cT3 or resectable cT4 tumors, neoadjuvant radiochemotherapy should be performed in squamous cell carcinomas or adenocarcinomas. Alternatively, perioperative chemotherapy can be carried out in adenocarcinoma. Palliative resections should be avoided and replaced by interventional procedures for palliation.
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21
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Yu Z, Li S, Liu D, Liu L, He J, Huang Y, Xu S, Mao W, Tan Q, Chen C, Li X, Zhang Z, Jiang G, Xu L, Zhang L, Fu J, Li H, Wang Q, Tan L, Li D, Zhou Q, Fu X, Jiang Z, Chen H, Fang W, Zhang X, Li Y, Tong T, Liu Y, Zhi X, Yan T, Zhang X, Gong L, Zhang H, Downs JB, Villamizar N, Gao S, He J. Society for Translational Medicine Expert Consensus on the prevention and treatment of postoperative pulmonary infection in esophageal cancer patients. J Thorac Dis 2018; 10:1050-1057. [PMID: 29607180 DOI: 10.21037/jtd.2018.01.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medicine, Beijing 100730, China
| | - Deruo Liu
- Department of Thoracic Surgery, China and Japan Friendship Hospital, Beijing 100029, China
| | - Lunxu Liu
- Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou 510000, China
| | - Yunchao Huang
- Department of Thoracic Surgery, Yunnan Cancer Hospital, Kunming 650100, China
| | - Shidong Xu
- Department of Thoracic surgery, Harbin Medical University Cancer Hospital, Harbin 150086, China
| | - Weimin Mao
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou 310000, China
| | - Qunyou Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital Fourth Military Medical University, Xi'an 710038, China
| | - Zhu Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai 200433, China
| | - Lin Xu
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing 210009, China
| | - Lanjun Zhang
- Cancer Center, San Yat-sen University, Guangzhou 510060, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Beijing 100049, China
| | - Qun Wang
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Lijie Tan
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Danqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Beijing 100032, China
| | - Qinghua Zhou
- Department of Lung Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhongmin Jiang
- Department of Thoracic Surgery, Shandong Qianfoshan Hospital, Jinan 250014, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200030, China.,Department of Thoracic Surgery, Shanghai Chest Hospital, Jiao Tong University, Shanghai 200030, China
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai 200030, China
| | - Xun Zhang
- Department of Thoracic Surgery, Tanjin Chest Hospital, Tianjin 300300, China
| | - Yin Li
- Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Ti Tong
- Department of Thoracic Surgery, The Second Hospital of Jilin University, Changchun 130062, China
| | - Yongyu Liu
- Department of Thoracic Surgery, Liaoning Cancer Hospital and Institute, Shenyang 110043, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital of Capital University of Medical Sciences, Beijing 100053, China
| | - Tiansheng Yan
- Department of Thoracic Surgery, Peking University Third Hospital, Beijing 100083, China
| | - Xingyi Zhang
- Department of Thoracic Surgery, The Second Hospital of Jilin University, Changchun 130062, China
| | - Lei Gong
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Hongdian Zhang
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - John B Downs
- Department of Anesthesiology and Critical Care Medicine, University of Florida, Gainesville, FL, USA
| | - Nestor Villamizar
- Department of Thoracic and Cardiac Surgery, University of Miami Jackson Memorial Hospital, Miami, FL, USA
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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22
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Fuchs HF, Schmidt HM, Meissner M, Brinkmann S, Maus M, Bludau M, Schröder W, Hölscher AH, Leers JM. Endoscopic and histopathologic reflux-associated mucosal damage in the remnant esophagus following transthoracic esophagectomy for cancer-5-year long-term follow-up. Dis Esophagus 2018; 31:1-6. [PMID: 29036607 DOI: 10.1093/dote/dox115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Despite a routine prescription of proton pump inhibitors, reflux-associated mucosal damage in the remnant esophagus is frequently observed. Purpose of this study is to evaluate mucosal damage in the esophageal remnant during long-term follow-up and to compare the prevalence of this damage between the subgroups of esophageal squamous cell and adenocarcinoma. All patients undergoing transthoracic Ivor-Lewis esophagectomy were prospectively entered in our IRB approved database. All patients underwent a routine check-up program with yearly surveillance endoscopies following esophagectomy. Only patients with a complete follow-up were included into this study. Endoscopic and histopathologic mucosal changes of the remnant esophagus were analyzed in close intervals. A total of 50 patients met the inclusion criteria, consisting of 31 adenocarcinomas (AC) and 19 squamous cell carcinomas (SCC). Mucosal damage was already seen 1 year after surgery in 20 patients macroscopically (43%) and in 21 patients microscopically (45%). At 5-year follow-up the prevalence for macroscopic and microscopic damage was 55% and 60%, respectively. The prevalence of mucosal damage was higher in AC patients than in SCC patients (1y-FU: 51% [AC] vs. 28% [SCC]; 5y-FU: 68% [AC] vs. 35% [SCC], P < 0.05). Newly acquired Barrett's esophagus was seen in 10 patients (20%) with two of those patients (20%) showing histopathologic proof of neoplasia. This study shows a high prevalence of reflux-associated mucosal damage in the remnant esophagus one year out of surgery and only a moderate increase in prevalence in the following years. Mucosal damage was more frequently seen in AC patients and the occurrence of de-novo Barrett's esophagus and de-novo neoplasia was high. Endoscopic surveillance with targeted biopsies seems to be an indispensable tool to follow patients after esophagectomy appropriately.
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Affiliation(s)
- H F Fuchs
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - H M Schmidt
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - M Meissner
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - S Brinkmann
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - M Maus
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - M Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
| | - A H Hölscher
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne.,Center for Esophageal- and Gastric Surgery, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - J M Leers
- Department of General, Visceral and Cancer Surgery, University Hospital, Cologne
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23
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Bollschweiler E, Plum P, Mönig SP, Hölscher AH. Current and future treatment options for esophageal cancer in the elderly. Expert Opin Pharmacother 2017; 18:1001-1010. [DOI: 10.1080/14656566.2017.1334764] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Elfriede Bollschweiler
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Patrick Plum
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Stefan P. Mönig
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Service de Chirurgie viscéral, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Arnulf H. Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Department of Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
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24
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Lambertz R, Drinhaus H, Schedler D, Bludau M, Schröder W, Annecke T. [Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]. Anaesthesist 2017; 65:458-66. [PMID: 27245922 DOI: 10.1007/s00101-016-0179-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.
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Affiliation(s)
- R Lambertz
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Uniklinik Köln, Köln, Deutschland
| | - H Drinhaus
- Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinik Köln, Kerpenerstr. 62, 50937, Köln, Deutschland
| | - D Schedler
- Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinik Köln, Kerpenerstr. 62, 50937, Köln, Deutschland
| | - M Bludau
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Uniklinik Köln, Köln, Deutschland
| | - W Schröder
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Uniklinik Köln, Köln, Deutschland
| | - T Annecke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinik Köln, Kerpenerstr. 62, 50937, Köln, Deutschland.
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25
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Lindner K, Lübbe L, Müller AK, Palmes D, Senninger N, Hummel R. Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy. Dis Esophagus 2017; 30:1-8. [PMID: 27060908 DOI: 10.1111/dote.12459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.
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Affiliation(s)
- Kirsten Lindner
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Linda Lübbe
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Ann-Kathrin Müller
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Daniel Palmes
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Richard Hummel
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
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26
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Müller AK, Lenschow C, Palmes D, Senninger N, Hummel R, Lindner K. [Timing of esophagectomy in multimodal therapy of esophageal cancer: Impact of time interval between neoadjuvant therapy and surgery on outcome and response]. Chirurg 2016; 86:874-80. [PMID: 25662991 DOI: 10.1007/s00104-014-2916-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neoadjuvant radiochemotherapy [n(R)CT] has become the standard of care in the multimodal therapy concept for patients with locally advanced esophageal cancer; however, optimal timing of surgery is not clearly defined. OBJECTIVES The study analyzed whether the length of the interval between completion of n(R)CT and surgery can affect the postoperative outcome, tumor response and long-term survival. MATERIAL AND METHODS A total of 106 patients with adenocarcinoma and squamous cell carcinoma of the esophagus, treated between 2006 and 2013, were included in this study. On the basis of the median time interval to surgery, patients were divided into two groups [group A ≤ 40 days (n = 54) and group B > 40 days (n = 52)] and compared concerning demographic data, preoperative risk scores, morbidity, outcome, tumor response and long-term survival. RESULTS The groups were comparable in terms of demographics, preoperative condition of the patients, complications and outcome; however, group A showed a trend towards a higher mortality risk as preoperatively assessed by the physiological and operative severity score for the enumeration of mortality and morbidity in esophagogastric surgery patients (O-POSSUM) (p = 0.064) and group B showed a trend towards a higher rate of complete responders (p = 0.097). CONCLUSION Concerning perioperative morbidity and mortality, delayed surgery after n(R)CT showed no benefit for the patient's outcome; however, the rate of complete tumor response was higher in patients with a time interval of more than 40 days, although this did not influence long-term survival or recurrence rates.
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Affiliation(s)
- A-K Müller
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Waldeyerstr. 1, 48149, Münster, Deutschland
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27
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Chen SY, Molena D, Stem M, Mungo B, Lidor AO. Post-discharge complications after esophagectomy account for high readmission rates. World J Gastroenterol 2016; 22:5246-5253. [PMID: 27298567 PMCID: PMC4893471 DOI: 10.3748/wjg.v22.i22.5246] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/05/2016] [Accepted: 04/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify rates of post-discharge complications (PDC), associated risk factors, and their influence on early hospital outcomes after esophagectomy.
METHODS: We used the 2005-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients ≥ 18 years of age who underwent an esophagectomy. These procedures were categorized into four operative approaches: transhiatal, Ivor-Lewis, 3-holes, and non-gastric conduit. We selected patient data based on clinical relevance to patients undergoing esophagectomy and compared demographic and clinical characteristics. The primary outcome was PDC, and secondary outcomes were hospital readmission and reoperation. The patients were then divided in 3 groups: no complication (Group 1), only pre-discharge complication (Group 2), and PDC patients (Group 3). A modified Poisson regression analysis was used to identify risk factors associated with developing post-discharge complication, and risk ratios were estimated.
RESULTS: 4483 total patients were identified, with 8.9% developing PDC within 30-d after esophagectomy. Patients who experienced complications post-discharge had a median initial hospital length of stay (LOS) of 9 d; however, PDC occurred on average 14 d following surgery. Patients with PDC had greater rates of wound infection (41.0% vs 19.3%, P < 0.001), venous thromboembolism (16.3% vs 8.9%, P < 0.001), and organ space surgical site infection (17.1% vs 11.0%, P = 0.001) than patients with pre-discharge complication. The readmission rate in our entire population was 12.8%. PDC patients were overwhelmingly more likely to have a reoperation (39.5% vs 22.4%, P < 0.001) and readmission (66.9% vs 6.6%, P < 0.001). BMI 25-29.9 and BMI ≥ 30 were associated with increased risk of PDC compared to normal BMI (18.5-25).
CONCLUSION: PDC after esophagectomy account for significant number of reoperations and readmissions. Efforts should be directed towards optimizing patient’s health pre-discharge, with possible prevention programs at discharge.
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28
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Lindner K, Fritz M, Haane C, Senninger N, Palmes D, Hummel R. Postoperative complications do not affect long-term outcome in esophageal cancer patients. World J Surg 2015; 38:2652-61. [PMID: 24867467 DOI: 10.1007/s00268-014-2590-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients. METHODS Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study. RESULTS SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival. CONCLUSIONS This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.
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Affiliation(s)
- Kirsten Lindner
- Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Münster, Germany,
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29
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Bludau M, Hölscher AH, Bollschweiler E, Leers JM, Gutschow CA, Brinkmann S, Schröder W. Preoperative airway colonization prior to transthoracic esophagectomy predicts postoperative pulmonary complications. Langenbecks Arch Surg 2015; 400:707-14. [PMID: 26252998 DOI: 10.1007/s00423-015-1326-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/27/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications. METHODS In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (<24 h, 24-72 h, >72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints. RESULTS In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p < 0.001), and a higher frequency of re-intubation (p < 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p < 0.0001). CONCLUSION PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.
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Affiliation(s)
- M Bludau
- Department of General, Visceral and Cancer Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Warnell I, Chincholkar M, Eccles M. Predicting perioperative mortality after oesophagectomy: a systematic review of performance and methods of multivariate models. Br J Anaesth 2015; 114:32-43. [DOI: 10.1093/bja/aeu294] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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31
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Paul S, Altorki N. Outcomes in the management of esophageal cancer. J Surg Oncol 2014; 110:599-610. [PMID: 25146593 DOI: 10.1002/jso.23759] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 07/21/2014] [Indexed: 12/25/2022]
Abstract
Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.
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Affiliation(s)
- Subroto Paul
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY
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32
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Individual risk modelling for esophagectomy: a systematic review. J Gastrointest Surg 2014; 18:1532-42. [PMID: 24760219 DOI: 10.1007/s11605-014-2524-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/31/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A number of models have been applied to predict outcomes from esophagectomy. This systematic review aimed to compare their clinical credibility, methodological quality and performance. METHODS A systematic review of the PubMed, EMBASE and Cochrane databases was performed in October 2012. Model and study quality were appraised using the framework of Minne et al. RESULTS Twenty studies were included in total; these were heterogeneous, retrospective and conducted over a number of years; all models were generated via logistic regression. Overall mortality was high, and consequently not representative of current practice. Clinical credibility and methodological quality were variable, with frequent failure to perform internal validation and variable presentation of calibration and discrimination metrics. P-POSSUM demonstrated the best calibration and discrimination for predicting mortality. Other than the Southampton score (which has yet to be externally validated) and the Amsterdam score, no studies had utility in predicting complications. CONCLUSION Whilst a number of models have been developed, adapted or trialled, due to numerous limitations, larger and more contemporary studies are required to develop and validate models further. The role of alternative techniques such as decision tree analysis and artificial neural networks is not known.
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33
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[Modern diagnostics and stage-oriented surgery: therapy of adenocarcinoma of the esophagogastric junction]. Chirurg 2013; 83:702-8, 710-1. [PMID: 22878576 DOI: 10.1007/s00104-011-2264-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The basis for decision-making about an individualized surgical treatment of adenocarcinoma of the esophagogastric junction is tumor staging and exact evaluation of the topography of the tumor in the small junctional area. The diagnostics mainly comprise endoscopy, biopsy, endosonography, computed tomography and partially diagnostic laparoscopy. This results in a clinical TNM staging and an evaluation according to the AEG classification from oral to aboral in type I (esophagus), type II (cardia) and type III (subcardia). Endoscopic resection is only appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. This is combined with neoadjuvant treatment in case of T3 or resectable T4 carcinomas. A type I carcinoma is removed by radical transthoracic en bloc esophagectomy with high intrathoracic esophagogastrostomy after gastric pull-up. In case of type II or III carcinomas, a transhiatal extended gastrectomy including distal esophageal resection is performed with reconstruction by Roux en Y esophagojejunostomy in the lower mediastinum. However, some advanced type II carcinomas which cannot be resected R0 at the esophagus need esophagectomy and gastric pull-up. This surgical strategy is justified by the topography of the lesion and the corresponding lymphatic drainage. Very rare indications are seen for a limited resection with interposition of small bowel in some mucosal carcinomas or total esophagogastrectomy with colon interposition in very advanced tumors. The neoadjuvant treatment comprises especially chemoradiation for type I and chemotherapy for type II and III carcinomas and leads to a significant survival benefit compared to surgery alone.
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Koppert LB, Lemmens VEPP, Coebergh JWW, Steyerberg EW, Wijnhoven BPL, Tilanus HW, Janssen-Heijnen MLG. Impact of age and co-morbidity on surgical resection rate and survival in patients with oesophageal and gastric cancer. Br J Surg 2013; 99:1693-700. [PMID: 23132417 DOI: 10.1002/bjs.8952] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Major surgery for cancer has become safer, including for elderly patients with co-morbidity. The aim of this study was to investigate the association between patient characteristics, resection rates and survival among patients with oesophageal or gastric cancer. METHODS The prospective Dutch population-based Eindhoven Cancer Registry for oesophagogastric cancers diagnosed between 1995 and 2009 was studied retrospectively for patient characteristics including co-morbidity. Logistic regression analysis was performed to assess the likelihood of resection in patients with tumour node metastasis (TNM) stage I-III lesions. Cox proportional hazard analysis was used to estimate hazard ratios (HRs) for survival. RESULTS The database contained information on 923 patients with oesophageal squamous cell carcinoma, 1181 with distal oesophageal, 942 with cardia and 3177 with subcardia cancer. Of patients with TNM stage I-III disease, 20·8 per cent (557 of 2680 patients) did not undergo resection. Age 70 years or above was associated with a lower likelihood of resection for distal oesophageal (odds ratio (OR) 0·24, 95 per cent confidence interval (c.i.) 0·14 to 0·41) and gastric (cardia: OR 0·41, 0·22 to 0·76; subcardia: OR 0·68, 0·48 to 0·97) cancer. The 30-day mortality rate increased with age (4·7 per cent in patients aged less than 70 years versus 11·9 per cent in those aged 70 years or more; P < 0·001) and co-morbidity (no co-morbidity, 3·6 per cent; 1 co-morbidity, 8·6 per cent; 2 or more co-morbidities, 11·2 per cent; P = 0·015). Surgery (compared with no surgery) was independently associated with better survival for all tumour types. After adjustment for treatment differences, age 70 years or above and presence of two or more co-morbidities were independently associated with poorer survival, especially in patients with subcardia carcinoma (age 70 years or more: HR 1·27, 95 per cent c.i. 1·17 to 1·48; co-morbidity: HR 1·33, 1·21 to 1·62). CONCLUSION Surgical compared with non-surgical treatment of oesophagogastric cancer was associated with better survival, but postoperative mortality was increased in patients of advanced age and with greater co-morbidity.
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Affiliation(s)
- L B Koppert
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Multimodal treatment of esophageal cancer. Langenbecks Arch Surg 2012; 398:177-87. [PMID: 22971784 DOI: 10.1007/s00423-012-1001-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/03/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses. METHODS Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma. RESULTS Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery. CONCLUSION This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.
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Semrau R, Herzog SL, Vallböhmer D, Kocher M, Hölscher AH, Müller RP. Prognostic factors in definitive radiochemotherapy of advanced inoperable esophageal cancer. Dis Esophagus 2012; 25:545-54. [PMID: 22133297 DOI: 10.1111/j.1442-2050.2011.01286.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to assess the efficacy and prognostic factors of definitive radiochemotherapy (RCT) for inoperable esophageal cancer. Between 1995 and 2005 all patients with inoperable esophageal cancer that underwent concurrent RCT were included in this retrospective study. Conventional computed tomography-based treatment planning as well as 3D-conformal radiotherapy (RT) was used. Maximum radiotherapy dose was 63 Gy. Chemotherapy consisted of cisplatin (20 mg/m(2) d1-5 and 29-33) and 5-FU (650-1000 mg/m(2) d1-5 and 29-33). Patients not suitable for RCT received radiotherapy alone. Toxicity was measured according to common toxicity criteria (CTC). Two hundred three consecutive patients with inoperable esophageal cancer that received definitive therapy were identified in this time period (160 with squamous cell carcinoma and 43 with adenocarcinoma). The 2-year overall survival probability was 21.2% whereas the progression-free survival at 2 years was 13.8% for all patients. In the univariate analysis, type of histology, T-stage, N-stage, application of chemotherapy, and the radiation dose were significantly correlated with overall/progression-free survival. Moreover, multivariate analysis revealed an independent prognostic impact for N-stage, radiation dose, and concurrent chemotherapy. Definitive RCT is an important palliative treatment option for patients with inoperable esophageal cancer. N-stage, radiation dose, and concurrent chemotherapy are important prognostic factors for survival.
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Affiliation(s)
- R Semrau
- Department of Radiation Oncology, University of Cologne, Cologne, Germany.
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Semrau R, Herzog SL, Vallböhmer D, Kocher M, Hölscher A, Müller RP. Radiotherapy in elderly patients with inoperable esophageal cancer. Is there a benefit? Strahlenther Onkol 2012; 188:226-32. [PMID: 22318327 DOI: 10.1007/s00066-011-0039-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 12/02/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Radiation oncologists increasingly face elderly cancer patients impaired by comorbidities and reduced performance status. As less data are available for this particular group of patients, the aim of the study was to assess the prognosis of inoperable esophageal cancer patients ≥ 70 years undergoing definitive radiotherapy or radiochemotherapy. PATIENTS AND TREATMENT PROTOCOL: Patients aged ≥ 70 with inoperable carcinoma of the esophagus undergoing definitive radio(chemo)therapy between 1995 and 2006 at the University of Cologne were included retrospectively. Maximal total dose of radiotherapy administered was 63 Gy (5 × 1.8 Gy/week). Chemotherapy consisted of cisplatin (20 mg/m(2) on days 1-5 and days 29-33) and 5-fluorouracil (650-1,000 mg/m(2) on days 1-5 and days 29-33). Efficacy was compared with a cohort of 152 patients < 70 years treated with the same protocol during the same time period. RESULTS A total of 51 patients aged ≥ 70 with inoperable cancer of the esophagus undergoing definitive therapy were identified (stage I/II 23.5%, stage III 56.9%, stage IV 9.8%; squamous cell carcinoma 74.5%, adenocarcinoma 25.5%). While 15 patients (29.4%) received combined radiochemotherapy (RCT), 40 patients (70.6%) were treated with radiotherapy alone (RT). Median progression-free survival (PFS) was 9.5 months; median overall survival (OS) was 13.9 months. Patients treated with RCT had a 2-year OS rate of 53.3% compared with 16.7% for RT patients (p = 0.039). The 2-year OS for clinically lymph node negative patients was 38.5% compared with 21.2% for lymph node positive patients (p = 0.072). Median OS was not significantly different between patients ≥ 70 years versus the patient cohort (n = 152) aged < 70 years (13.9 vs. 7.2 months, p = 0.072) but PFS showed a significant difference (4.9 vs. 9.5 months, p = 0.026) in favor of the > 70 years group. CONCLUSION Prognosis in elderly patients with inoperable esophageal cancer undergoing definitive radiotherapy/radiochemotherapy is limited, although it is not inferior to patients < 70 years.
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Affiliation(s)
- R Semrau
- Department of Radiation Oncology, University of Cologne, Kerpener Str. 62, 50924, Cologne, Germany.
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Abstract
Esophageal cancer, although considered uncommon in the United States, continues to exhibit increased incidence. Esophageal cancer now ranks seventh among cancers in mortality for men in the United States. Even as treatment continues to advance, the mortality rate remains high, with a 5-year survival rate less than 35%. Esophageal cancer typically is discovered in advanced stages, which reduces the treatment options. When disease is locally advanced, esophagectomy remains the standard for treatment. Surgery remains challenging and complicated. Multiple surgical approaches are available, with the choice determined by tumor location and stage of disease. Recovery is often fraught with complications-both physical and emotional. Nursing care revolves around complex care managing multiple body systems and providing effective education and emotional support for both patients and patients' families. Even after recovery, local recurrence and distant metastases are common. Early diagnosis, surgical advancement, and improvements in postoperative care continue to improve outcomes.
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Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Iscimen R, Brown DR, Cassivi SD, Keegan MT. Intensive Care Unit Utilization and Outcome After Esophagectomy. J Cardiothorac Vasc Anesth 2010; 24:440-6. [DOI: 10.1053/j.jvca.2008.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Indexed: 11/11/2022]
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Paul S, Altorki NK. Complications of Esophageal Resection. COMPLICATIONS IN CARDIOTHORACIC SURGERY 2009:228-246. [DOI: 10.1002/9781444307580.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Toh Y, Oki E, Minami K, Okamura T. Evaluation of the feasibility and safety of immediate extubation after esophagectomy with extended radical three-field lymph node dissection for thoracic esophageal cancers. Esophagus 2009. [DOI: 10.1007/s10388-009-0198-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
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Zingg U, Langton C, Addison B, Wijnhoven BPL, Forberger J, Thompson SK, Esterman AJ, Watson DI. Risk prediction scores for postoperative mortality after esophagectomy: validation of different models. J Gastrointest Surg 2009; 13:611-8. [PMID: 19050980 DOI: 10.1007/s11605-008-0761-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 11/12/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Different prediction models for operative mortality after esophagectomy have been developed. The aim of this study is to independently validate prediction models from Philadelphia, Rotterdam, Munich, and the ASA. METHODS The scores were validated using logistic regression models in two cohorts of patients undergoing esophagectomy for cancer from Switzerland (n = 170) and Australia (n = 176). RESULTS All scores except ASA were significantly higher in the Australian cohort. There was no significant difference in 30-day mortality or in-hospital death between groups. The Philadelphia and Rotterdam scores had a significant predictive value for 30-day mortality (p = 0.001) and in-hospital death (p = 0.003) in the pooled cohort, but only the Philadelphia score had a significant prediction value for 30-day mortality in both cohorts. Neither score showed any predictive value for in-hospital death in Australians but were highly significant in the Swiss cohort. ASA showed only a significant predictive value for 30-day mortality in the Swiss. For in-hospital death, ASA was a significant predictor in the pooled and Swiss cohorts. The Munich score did not have any significant predictive value whatsoever. CONCLUSION None of the scores can be applied generally. A better overall predictive score or specific prediction scores for each country should be developed.
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Affiliation(s)
- U Zingg
- Flinders University Department of Surgery, Flinders Medical Center, Flinders Drive, Bedford Park, Adelaide, 5042, South Australia, Australia.
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Schröder W, Wirths K, Gutschow C, Vallböhmer D, Bludau M, Schumacher B, Neuhaus H, Hölscher AH. Transthoracic esophagectomy after endoscopic mucosal resection in patients with early esophageal carcinoma. J Gastrointest Surg 2009; 13:223-9. [PMID: 18923875 DOI: 10.1007/s11605-008-0719-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 09/24/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION For patients with esophageal carcinoma limited to the mucosa endoscopic mucosal resection (EMR) is the therapy of choice whereas surgical resection is advocated for submucosal tumors. METHODS This study analyzes the histopathologic results of patients with early esophageal carcinoma who underwent EMR prior to transthoracic esophagectomy. Sixteen patients with early esophageal carcinoma and EMR as first line treatment were included in this retrospective study. Ten patients underwent transthoracic esophagectomy because of submucosal infiltration combined incomplete tumor resection at the lateral/basal resection margin. In one patient each, surgical therapy was indicated due to submucosal infiltration or incomplete resection only. Three patients underwent surgical resection due to residual neoplasia within an esophageal stenosis following EMR. Surgical specimens were examined for pT and pN stage according to the UICC. RESULTS Three patients had a squamous cell carcinoma (SCC) and 13 patients an adenocarcinoma (AC), nine patients with a long segment Barrett's esophagus. The distribution of the pT stages was as follows: 6x pT0 (no histopathologic evidence of residual tumor), 1x pT1m1, 1x pT1m2, 3x pT1m3, 1x pT1sm1, 1x pT1sm2, 1x pT2, and 2x pT3. Three of 16 patients (18.8%) with a pT1sm1, pT2, and pT3 stage had nodal metastases. In all three patients metastatic nodes were located in the mediastinum. In two patients, a second carcinoma was detected during histopathologic work-up (1x AC in the cardia and 1x SCC in the cervical esophagus). CONCLUSION The data of this highly selected patients indicate that the boundary between the therapy of mucosal and submucosal tumors is not as clear as stated. Therefore, treatment of early esophageal carcinoma demands a close interdisciplinary cooperation.
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Affiliation(s)
- W Schröder
- Department of Visceral and Vascular Surgery, University of Cologne, Kerperner Str. 62, 50937 Cologne, Germany.
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Schmidt M, Bollschweiler E, Dietlein M, Mönig SP, Kobe C, Vallboehmer D, Eschner W, Hölscher A, Schicha H. Mean and maximum standardized uptake values in [18F]FDG-PET for assessment of histopathological response in oesophageal squamous cell carcinoma or adenocarcinoma after radiochemotherapy. Eur J Nucl Med Mol Imaging 2008; 36:735-44. [DOI: 10.1007/s00259-008-1011-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 11/07/2008] [Indexed: 12/12/2022]
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Metzger R, Drebber U, Baldus SE, Mönig SP, Hölscher AH, Bollschweiler E. Extracapsular Lymph Node Involvement Differs Between Squamous Cell and Adenocarcinoma of the Esophagus. Ann Surg Oncol 2008; 16:447-53. [DOI: 10.1245/s10434-008-0248-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 11/01/2008] [Accepted: 11/02/2008] [Indexed: 12/15/2022]
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Bollschweiler E, Metzger R, Drebber U, Baldus S, Vallböhmer D, Kocher M, Hölscher AH. Histological type of esophageal cancer might affect response to neo-adjuvant radiochemotherapy and subsequent prognosis. Ann Oncol 2008; 20:231-8. [PMID: 18836090 DOI: 10.1093/annonc/mdn622] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study investigates response and prognosis after neo-adjuvant chemoradiation (CTx/RTx) in patients with advanced esophageal carcinoma, according to histological type. PATIENTS AND METHODS Patients with uT3 carcinoma of the esophagus treated with curative-intention esophagectomy from 1997 until 2006 were included in this retrospective analysis. Patients receiving preoperative CTx/RTx (5-fluorouracil, cisplatin, 36 Gy) were compared with those with primary surgery for pT3 tumors. Therapy response after CTx/RTx was evaluated using 'Cologne Regression Grade' (minor response: >or=10% vital residual tumor cells (VRTCs), major response: <10% VRTC or pathologic complete response). Prognosis was evaluated for adenocarcinoma (AC) and squamous cell carcinoma (SCC). RESULTS Of 297 patients, 52% were SCC and 48% AC. In all, 192 patients underwent CTx/RTx, 100 (65%) SCC and 92 (64%) AC (nonsignificant). In SCC group 51% and in AC group 29% achieved major response (P < 0.01). Patients with major response had a 2-year survival rate (2y-SR) of 78% versus those with minor response or without CTx/RTx, with a 2y-SR of 45% (P = 0.001). Examining patients with major response exclusively, the prognosis of AC (2y-SR 85%) is better than that of SCC (2y-SR 54%) (P < 0.01). CONCLUSION This retrospective study concludes that in esophageal tumors, response to and prognosis after neo-adjuvant CTx/RTx vary according to histology.
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Affiliation(s)
- E Bollschweiler
- Department of General-, Visceral- and Cancer Surgery, University of Cologne, Germany.
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Raue W, Haase O, Langelotz C, Neuss H, Müller JM, Schwenk W. Influence of pre-operative fluid infusion on volume status during oesophageal resection--a prospective trial. Acta Anaesthesiol Scand 2008; 52:1218-25. [PMID: 18823460 DOI: 10.1111/j.1399-6576.2008.01759.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Perioperative fluid therapy is controversially debated in surgery. In malnourished and hypovolaemic patients, a restrictive fluid regimen may lead to hypoperfusion and increased incidence of complications. The present prospective cohort study was performed to assess whether pre-operative i.v. fluid administration improves intraoperative cardiac preload in patients undergoing oesophageal resection. METHODS Intraoperatively, the intrathoracic blood volume index (ITBVI) was monitored in 44 consecutive patients undergoing elective oesophagectomies with the transthoracic thermodilution technique. Twenty-two of these patients received a pre-operative i.v. fluid loading with a balanced crystalloid solution (1 ml/kg/h over 48 h). RESULTS After induction of anaesthesia ITBVI was low but not different between the groups [767 (512-1314) vs. 775 (531-1200) ml/m(2), P=0.81]. In the intervention group, the extravascular lung water increased above normal levels during the operation. The groups did not differ in cardiac output, blood pressure, heart rate and central venous pressure. Post-operative morbidity was not different between the cohorts. CONCLUSION Pre-operative i.v. fluid loading with crystalloid solutions could not be shown to improve the intraoperative volume status and cardiac function in this study. Randomised trials with other volume replacement techniques are recommended.
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Affiliation(s)
- W Raue
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité- University Medicine Berlin, Berlin, Germany.
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Lagarde SM, Reitsma JB, Maris AKD, van Berge Henegouwen MI, Busch OR, Obertop H, Zwinderman AH, van Lanschot JJB. Preoperative Prediction of the Occurrence and Severity of Complications After Esophagectomy for Cancer With Use of a Nomogram. Ann Thorac Surg 2008; 85:1938-45. [DOI: 10.1016/j.athoracsur.2008.03.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 01/03/2008] [Accepted: 03/05/2008] [Indexed: 11/26/2022]
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Vallböhmer D, Hölscher AH, Brabender J, Prenzel K, Gutschow C, Schröder W, Metzger R, Bollschweiler E. Clinicopathologic and prognostic factors of young and elderly patients with esophageal adenocarcinoma: is there really a difference? Dis Esophagus 2008; 21:596-600. [PMID: 18430182 DOI: 10.1111/j.1442-2050.2008.00817.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Evidence suggests a significant difference in the incidence, presentation, and outcome of young and elderly patients with esophageal adenocarcinoma. We aimed to compare clinicopathologic and prognostic factors of young and elderly patients with esophageal adenocarcinoma at a surgical department in Europe. From 1996 to 2006, 223 patients with a resectable esophageal adenocarcinoma were analyzed and divided in three groups: (i) patients <or=50 years (n = 40); (ii) patients between 50 and 70 years (n = 131); and (iii) patients >70 years (n = 52). Clinicopathological and prognostic factors were compared between these groups. The total number of patients with esophageal adenocarcinoma increased significantly. Although the total number of patients <or=50 years increased over the years, the proportion of young patients with esophageal adenocarcinoma was rather constant. The number of patients with a pT1-tumor was similar among all groups. Young patients had a significantly lower comorbidity and received more often a neoadjuvant radio-chemotherapy. The 5-year survival rate of young patients was significantly higher compared with elderly patients. In this European population, the total number of patients with adenocarcinoma of the esophagus increased dramatically in recent years, but the number of young patients remained rather constant. The better prognosis of young patients is mainly caused by less comorbidity and more frequent use of neoadjuvant therapy.
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Affiliation(s)
- D Vallböhmer
- Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany
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