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Schiefer S, Crnovrsanin N, Rompen IF, Jorek N, Al-Saeedi M, Schmidt T, Nienhüser H, Sisic L. Validation of mortality risk scores after esophagectomy. J Cancer Res Clin Oncol 2025; 151:51. [PMID: 39875671 PMCID: PMC11775027 DOI: 10.1007/s00432-024-06074-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Accepted: 12/27/2024] [Indexed: 01/30/2025]
Abstract
PURPOSE Oncological esophagectomy is the mainstay in esophageal cancer treatment, but perioperative mortality remains a significant concern. Various scoring systems exist to identify patients at high risk for postoperative complications and death. In the following, we aim to evaluate and compare these different scoring systems. METHODS We analyzed data from 714 patients who underwent esophagectomy between 2002 and 2021. Each patient's risk was calculated using three models: the International Esodata Study Group (IESG) 90-day mortality risk prediction, the Steyerberg 30-day mortality score, and the Fuchs et al. preoperative in-hospital mortality score (Fuchs score). The diagnostic performance of these models was assessed using the area under the receiver operating characteristic (ROC) curves. RESULTS Of the 714 patients, the majority (87.67%) underwent abdomino-thoracic esophagectomy with intrathoracic anastomosis. The IESG score classified 52.1% as very low, 26.6% low, 17.5% middle, 2.8% high, and 1% as very high risk, while the Fuchs score identified 94.5% as low-risk and 5.5% as high-risk patients. Mortality rates were 6.9% at 90 days, 3.4% at 30 days, and 6.7% in-hospital. The area under the ROC curve was 0.634 (95%CI: 0.557-0.712) for the IESG model, 0.637 (95%CI: 0.526-0.747) for the Steyerberg score, and 0.686 (95%CI: 0.611-0.760) for the Fuchs score. CONCLUSIONS Existing risk score systems provide a possibility for preoperative risk stratification, particularly for identifying high-risk patients. However, due to their limited predictive ability, improvements are needed to apply these strategies effectively in clinical practice.
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Affiliation(s)
- Sabine Schiefer
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nerma Crnovrsanin
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ingmar F Rompen
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicolas Jorek
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Henrik Nienhüser
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Leila Sisic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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Sakowitz S, Bakhtiyar SS, Mallick S, Yanagawa J, Benharash P. Travel to High-Volume Centers and Survival After Esophagectomy for Cancer. JAMA Surg 2025; 160:19-27. [PMID: 39535737 PMCID: PMC11561720 DOI: 10.1001/jamasurg.2024.5009] [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: 03/31/2024] [Accepted: 08/24/2024] [Indexed: 11/16/2024]
Abstract
Importance Ongoing efforts have encouraged the regionalization of esophageal adenocarcinoma treatment to high-volume centers (HVCs). Yet such centralization has been linked with increased patient travel burden and reduced postoperative continuity of care. Objective To determine whether traveling to undergo esophagectomy at HVCs is linked with superior overall survival compared with receiving care locally at low-volume centers (LVC). Design, Setting, and Participants This cohort study considered data for all patients diagnosed with stage I through III esophageal adenocarcinoma in the 2010-2021 National Cancer Database. Patients were stratified based on distance traveled to receive care and the annual esophagectomy volume at the treating hospital: the travel-HVC cohort included patients in the top 25th percentile of travel burden who received care at centers in the top volume quartile, and the local-LVC cohort represented those in the bottom 25th percentile of travel burden who were treated at centers in the lowest volume quartile. Data were analyzed from July 2023 to January 2024. Main Outcomes and Measures The primary end points were overall survival at 1 year and 5 years. Secondary end points included perioperative outcomes and factors linked with traveling to receive care. Results Of 17 970 patients, 2342 (13%) comprised the travel-HVC cohort, and 1969 (11%), the local-LVC cohort. The median (IQR) age was 65 (58-71) years; 3748 (87%) were male and 563 (13%) were female. After risk adjustment and with care at local LVCs as the reference, traveling to HVC was associated with superior survival at 1 year (hazard ratio for mortality [HR], 0.69; 95% CI, 0.58-0.83) and 5 years (HR, 0.80; 95% CI, 0.70-0.90). Stratifying by stage, traveling to HVCs was associated with comparable outcomes for stage I disease but reduced mortality for stage III (1-year HR, 0.72; 95% CI, 0.60-0.87; 5-year HR, 0.83; 95% CI, 0.74-0.93). Further, traveling to HVC was associated with greater lymph node harvest (β, 5.08 nodes; 95% CI, 3.78-6.37) and likelihood of margin-negative resection (adjusted odds ratio, 1.83; 95% CI, 1.29-2.60). Conclusions and Relevance Traveling to HVCs for esophagectomy was associated with improved 1-year and 5-year survival compared with receiving care locally at LVCs, particularly among patients with locoregionally advanced disease. Future studies are needed to ascertain barriers to care and develop novel targeted pathways to ensure equitable access to high-volume facilities and high-quality oncologic care.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles
- Department of Surgery, University of Colorado, Aurora
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles
- Center for Advanced Surgical & Interventional Technology, Department of Surgery, University of California, Los Angeles
| | - Jane Yanagawa
- Division of Thoracic Surgery, Department of Surgery, University of California, Los Angeles
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles
- Center for Advanced Surgical & Interventional Technology, Department of Surgery, University of California, Los Angeles
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Morales-Conde S, Navarro-Morales L, Moreno-Suero F, Balla A, Licardie E. Fluorescence and tracers in surgery: the coming future. Cir Esp 2024; 102 Suppl 1:S45-S60. [PMID: 38851317 DOI: 10.1016/j.cireng.2024.05.011] [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: 05/07/2024] [Accepted: 05/23/2024] [Indexed: 06/10/2024]
Abstract
The revolution that we are seeing in the world of surgery will determine the way we understand surgical approaches in coming years. Since the implementation of minimally invasive surgery, innovations have constantly been developed to allow the laparoscopic approach to go further and be applied to more and more procedures. In recent years, we have been in the middle of another revolutionary era, with robotic surgery, the application of artificial intelligence and image-guided surgery. The latter includes 3D reconstructions for surgical planning, virtual reality, holograms or tracer-guided surgery, where ICG-guided fluorescence has provided a different perspective on surgery. ICG has been used to identify anatomical structures, assess tissue perfusion, and identify tumors or tumor lymphatic drainage. But the most important thing is that this technology has come hand in hand with the potential to develop other types of tracers that will facilitate the identification of tumor cells and ureters, as well as different light beams to identify anatomical structures. These will lead to other types of systems to assess tissue perfusion without the use of tracers, such as hyperspectral imaging. Combined with the upcoming introduction of ICG quantification, these developments represent a real revolution in the surgical world. With the imminent implementation of these technological advances, a review of their clinical application in general surgery is timely, and this review serves that aim.
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Affiliation(s)
- Salvador Morales-Conde
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Laura Navarro-Morales
- Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Francisco Moreno-Suero
- Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Andrea Balla
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Eugenio Licardie
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
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Takiguchi H, Koyanagi K, Ozawa S, Oguma T, Asano K. Detrimental impact of late-onset pneumonia on long-term prognosis in oesophageal cancer survivors. Respir Investig 2024; 62:531-537. [PMID: 38642419 DOI: 10.1016/j.resinv.2024.04.005] [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: 09/02/2023] [Revised: 02/15/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUD Oesophageal cancer patients are prone to early- and late-onset pneumonia after oesophagectomy. We aimed to investigate the incidence rate and impact on the long-term prognosis of late-onset pneumonia in oesophageal cancer survivors who survived for at least one year after oesophagectomy without cancer recurrence. METHODS We retrospectively reviewed 233 patients with thoracic oesophageal cancer who underwent oesophagectomy with gastric conduit reconstruction between September 2009 and June 2019 at a tertiary referral hospital in Japan. Pneumonia that occurred ≥1 year after oesophagectomy was defined as late-onset pneumonia. RESULTS Among the 185 oesophageal cancer survivors, 31 (17%) developed late-onset pneumonia. The cumulative incidence rates of late-onset pneumonia 24, 36, and 60 months after oesophagectomy were 6.4%, 10%, and 21%, respectively, whereas pneumonia recurred at 21%, 31%, and 52% within 6, 12, and 24 months, respectively, after the first pneumonia. Chronic obstructive pulmonary disease, postoperative anastomotic leakage, and loss of skeletal muscle mass were independently associated with late-onset pneumonia, and a combination of these factors further increased the risk. Late-onset pneumonia with hospitalisation had the greatest negative impact on the long-term prognosis as non-cancer deaths (HR, 21; p < 0.001), followed by recurrent late-onset pneumonia (HR, 18; p < 0.001). CONCLUSIONS Late-onset pneumonia in oesophageal cancer survivors is significantly associated with an increased risk of recurrent infections and non-cancer deaths. Chronic obstructive pulmonary disease and postoperative muscle loss are risk factors for late-onset pneumonia, and more intensive pharmacological and nutritional interventions should be considered to improve long-term prognosis after oesophagectomy.
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Affiliation(s)
- Hiroto Takiguchi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Soji Ozawa
- Department of Surgery, Tamakyuryo Hospital, Tokyo, 1940202, Japan
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan.
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Kaneoka A, Inokuchi H, Ueha R, Sato T, Goto T, Yamauchi A, Seto Y, Haga N. Longitudinal Analysis of Dysphagia and Factors Related to Postoperative Pneumonia in Patients Undergoing Esophagectomy for Esophageal Cancer. Dysphagia 2024; 39:376-386. [PMID: 37934250 PMCID: PMC11127821 DOI: 10.1007/s00455-023-10618-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/15/2023] [Indexed: 11/08/2023]
Abstract
Few studies have quantified longitudinal changes in swallowing in patients undergoing esophagectomy for esophageal cancer. This study longitudinally analyzed the changes in the Modified Barium Swallow Study Impairment Profile (MBSImP™) scores, swallowing kinematic measurements, and swallowing-related symptoms in patients undergoing esophagectomy. We also examined the association between identified swallowing impairment and aspiration pneumonia after surgery. We included consecutive patients who underwent esophagectomy and completed laryngoscopy and videofluoroscopy before, two weeks, and three months after surgery. We analyzed physiological impairments using the MBSImP. We also assessed the swallowing kinematics on a 5 mL thickened liquid bolus at three time points. Vocal fold mobility was assessed using a laryngoscope. Repeated measures were statistically examined for longitudinal changes in swallowing function. The association between the significant changes identified after esophagectomy and aspiration pneumonia was tested. Twenty-nine patients were included in this study. Preoperative swallowing function was intact in all participants. The timing of swallowing initiation and opening of the pharyngoesophageal segment remained unchanged after surgery. Tongue base retraction and pharyngeal constriction ratio worsened two weeks after surgery but returned to baseline levels three months after surgery. Three months after surgery, hyoid displacement and vocal fold immobility did not fully recover. Aspiration pneumonia occurred in nine patients after surgery and was associated with postoperative MBSImP pharyngeal residue scores. Decreased hyoid displacement and vocal fold immobility were observed postoperatively and persisted for a long time. The postoperative pharyngeal residue was associated with pneumonia and thus should be appropriately managed after surgery.
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Affiliation(s)
- Asako Kaneoka
- The University of Tokyo Hospital Rehabilitation Center, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan.
- The University of Tokyo Hospital Swallowing Center, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Haruhi Inokuchi
- The University of Tokyo Hospital Rehabilitation Center, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
- The University of Tokyo Hospital Swallowing Center, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Rumi Ueha
- The University of Tokyo Hospital Swallowing Center, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
- Department of Otorhinolaryngology and Head and Neck Surgery, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Taku Sato
- Department of Otorhinolaryngology and Head and Neck Surgery, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Takao Goto
- Department of Otorhinolaryngology and Head and Neck Surgery, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Akihito Yamauchi
- Department of Otorhinolaryngology and Head and Neck Surgery, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Nobuhiko Haga
- Rehabilitation Services Bureau, The National Rehabilitation Center for Persons With Disabilities, 4-1 Namiki, Tokorozawa, Saitama, 359-8555, Japan
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Zhang T, Wang H, Jin T, Wu Z, Li X, Zhang Q. Endoscopic submucosal dissection versus surgery for T1b esophageal carcinoma: a single-center retrospective study. J Cancer Res Clin Oncol 2024; 150:248. [DOI: https:/doi.org/10.1007/s00432-024-05724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/23/2024] [Indexed: 05/13/2024]
Abstract
Abstract
Introduction
Endoscopic submucosal dissection (ESD) is a preferred treatment option for superficial esophageal squamous cell carcinoma (SESCC). However, only few studies compared long-term survival outcomes of ESD with surgery, especially for T1b SESCC. This study compared the overall survival (OS), disease-free survival (DSS), recurrence-free survival (RFS), and complication rates of both, to evaluate the value of ESD in patients with T1b SESCC.
Methods
We reviewed patients who underwent ESD (n = 47) or surgery (n = 73) for T1b SESCC at Affiliated Hospital of Nanjing University of Chinese Medicine from 2009 to 2021. To increase the precision of our results interpretation, subgroups were analyzed according to the depth of tumor invasion and elderly people.
Results
In the ESD and surgery groups, the overall mortality rates were 0/100 and 12.3/100 person years, incidence rates of recurrence were 2.13/100 and 11/100 person years, respectively. Kaplan–Meier survival analysis revealed no significant different in OS, DSS and RFS. Charlson comorbidity index (CCI) and depth of submucosal invasion were identified as risk factors for cancer recurrence in multivariate analysis. For elderly people, no significant differences were found in OS, DSS and RFS between different treatments.
Conclusion
ESD are related to lower complication rates and shorter hospital stay than surgery in long-term outcomes for patients with pT1b SESCC. But in pT1b-SM2 patients, we still need long-term follow-up.
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Zhang T, Wang H, Jin T, Wu Z, Li X, Zhang Q. Endoscopic submucosal dissection versus surgery for T1b esophageal carcinoma: a single-center retrospective study. J Cancer Res Clin Oncol 2024; 150:248. [DOI: doi.org/10.1007/s00432-024-05724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/23/2024] [Indexed: 05/13/2024]
Abstract
Abstract
Introduction
Endoscopic submucosal dissection (ESD) is a preferred treatment option for superficial esophageal squamous cell carcinoma (SESCC). However, only few studies compared long-term survival outcomes of ESD with surgery, especially for T1b SESCC. This study compared the overall survival (OS), disease-free survival (DSS), recurrence-free survival (RFS), and complication rates of both, to evaluate the value of ESD in patients with T1b SESCC.
Methods
We reviewed patients who underwent ESD (n = 47) or surgery (n = 73) for T1b SESCC at Affiliated Hospital of Nanjing University of Chinese Medicine from 2009 to 2021. To increase the precision of our results interpretation, subgroups were analyzed according to the depth of tumor invasion and elderly people.
Results
In the ESD and surgery groups, the overall mortality rates were 0/100 and 12.3/100 person years, incidence rates of recurrence were 2.13/100 and 11/100 person years, respectively. Kaplan–Meier survival analysis revealed no significant different in OS, DSS and RFS. Charlson comorbidity index (CCI) and depth of submucosal invasion were identified as risk factors for cancer recurrence in multivariate analysis. For elderly people, no significant differences were found in OS, DSS and RFS between different treatments.
Conclusion
ESD are related to lower complication rates and shorter hospital stay than surgery in long-term outcomes for patients with pT1b SESCC. But in pT1b-SM2 patients, we still need long-term follow-up.
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Zhang T, Wang H, Jin T, Wu Z, Li X, Zhang Q. Endoscopic submucosal dissection versus surgery for T1b esophageal carcinoma: a single-center retrospective study. J Cancer Res Clin Oncol 2024; 150:248. [PMID: 38724804 PMCID: PMC11081981 DOI: 10.1007/s00432-024-05724-3] [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: 02/26/2024] [Accepted: 03/23/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a preferred treatment option for superficial esophageal squamous cell carcinoma (SESCC). However, only few studies compared long-term survival outcomes of ESD with surgery, especially for T1b SESCC. This study compared the overall survival (OS), disease-free survival (DSS), recurrence-free survival (RFS), and complication rates of both, to evaluate the value of ESD in patients with T1b SESCC. METHODS We reviewed patients who underwent ESD (n = 47) or surgery (n = 73) for T1b SESCC at Affiliated Hospital of Nanjing University of Chinese Medicine from 2009 to 2021. To increase the precision of our results interpretation, subgroups were analyzed according to the depth of tumor invasion and elderly people. RESULTS In the ESD and surgery groups, the overall mortality rates were 0/100 and 12.3/100 person years, incidence rates of recurrence were 2.13/100 and 11/100 person years, respectively. Kaplan-Meier survival analysis revealed no significant different in OS, DSS and RFS. Charlson comorbidity index (CCI) and depth of submucosal invasion were identified as risk factors for cancer recurrence in multivariate analysis. For elderly people, no significant differences were found in OS, DSS and RFS between different treatments. CONCLUSION ESD are related to lower complication rates and shorter hospital stay than surgery in long-term outcomes for patients with pT1b SESCC. But in pT1b-SM2 patients, we still need long-term follow-up.
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Affiliation(s)
- Ting Zhang
- Department of Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Hanying Wang
- Department of Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Tian Jin
- Department of Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Zeyu Wu
- Department of Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Xiuqing Li
- Department of Pathology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Qide Zhang
- Department of Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China.
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Guo J, Xu Y, Huang C, Wang M, Zhang F, Liu Z, Li Z, Lv H, Tian Z. Oblique conformal anastomosis decreased the risks of cervical anastomotic leakage after totally minimally invasive esophagectomy. Asian J Surg 2024:S1015-9584(24)00568-2. [PMID: 38604851 DOI: 10.1016/j.asjsur.2024.03.141] [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: 10/08/2023] [Revised: 12/08/2023] [Accepted: 03/22/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVE To investigate the effectiveness of the original oblique conformal anastomosis presented in this research in reducing the incidence of cervical anastomotic leak after performing totally minimally invasive esophagectomy (TMIE). METHODS The esophagus and stomach of 27 fresh pigs, termed the esophagogastric model, were used to simulate human esophagogastric organs for this study's in vitro experimental objectives. Nine esophagogastric models of similar weight were divided into three groups. Esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. A tension gauge was used to pull the anastomosis, and the tension at which anastomotic leakage occurred was recorded. Furthermore, a retrospective assessment of 539 patients who underwent TMIE was conducted to analyze the influencing factors of cervical anastomotic leakage. RESULTS Experiments on the esophagogastric models showed a higher fracture strength of oblique conformal anastomosis than that of conventional anastomosis (F2,18 = 40.86, P < 0.05), which was associated with a lower incidence of cervical anastomotic leakage (X2 = 9.0260, P = 0.0027). Retrospective analysis of 539 esophageal cancer patients who underwent TMIE showed that in contrast to conventional anastomosis, oblique conformal anastomosis was an independent protective factor against cervical anastomotic leakage (P = 0.0462, OR = 0.5872, 95% CI = 0.3497-0.9993). CONCLUSION Oblique conformation anastomosis was stronger and involved a more prominent reduced risk of cervical anastomotic leakage than conventional anastomosis after TMIE.
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Affiliation(s)
- Jinyang Guo
- Emergency Department, The Affiliated Hospital of Chengde Medical University, China
| | - Yanzhao Xu
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Chao Huang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Mingbo Wang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Fan Zhang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Zhao Liu
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Zhenhua Li
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Huilai Lv
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, China
| | - Ziqiang Tian
- Fourth Hospital of Hebei Medical University, China.
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Hayashi Y, Motoori M, Miyazaki Y, Maekawa S, Nishizawa Y, Komatsu H, Inoue A, Kagawa Y, Tomokuni A, Fujitani K. Impact of the perioperative assessment of deglutition on postoperative respiratory complications in elderly patients undergoing gastrectomy for gastric cancer. Surg Today 2024; 54:258-265. [PMID: 37458836 DOI: 10.1007/s00595-023-02728-3] [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: 03/15/2023] [Accepted: 06/26/2023] [Indexed: 02/20/2024]
Abstract
PURPOSE To investigate the association between perioperative deglutition screening and postoperative respiratory complications (PRCs) in elderly patients undergoing gastrectomy for gastric cancer. METHODS We analyzed data from 86 patients with gastric cancer (aged ≥ 70 years) who underwent gastrectomy between October, 2016 and November, 2018. Videofluoroscopic swallowing examinations (VFSEs) were performed before and after surgery. We examined the association of these results with postoperative respiratory complications, as well as the relationships between demographic, operative, and swallowing function assessment data. RESULTS PRCs were identified in 16 patients. The results of pre- and postoperative VFSE showed abnormalities in 28 and 32 patients, respectively. Multivariate analysis revealed that abnormalities in the postoperative VFSEs were strongly associated with the development of PRCs (P = 0.002). The findings of this analysis suggests that ventilatory impairment, a Charlson comorbidity index score ≥ 3, and an open surgical approach are independent risk factors for PRCs. CONCLUSION This is the first study to demonstrate the efficacy of perioperative assessment of swallowing function using VFSE for predicting PRCs in elderly patients undergoing gastrectomy for gastric cancer.
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Affiliation(s)
- Yoshinori Hayashi
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masaaki Motoori
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan.
| | - Yasuhiro Miyazaki
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Shizuka Maekawa
- Department of Rehabilitation, Osaka General Medical Center, Osaka, Japan
| | - Yujiro Nishizawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Hisateru Komatsu
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Akira Inoue
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Akira Tomokuni
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
| | - Kazumasa Fujitani
- Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-Ku, Osaka, 558-8558, Japan
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11
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An KR, Seijas V, Xu MS, Grüßer L, Humar S, Moreno AA, Turk M, Kasanagottu K, Alzghari T, Dimagli A, Ko MA, Villena-Vargas J, Papatheodorou S, Gaudino MFL. Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis. Dis Esophagus 2024; 37:doad066. [PMID: 38018252 DOI: 10.1093/dote/doad066] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.
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Affiliation(s)
- Kevin R An
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Vanessa Seijas
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Division of Rehabilitation, Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Ageing, Functioning Epidemiology, and Implementation, Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Physical and Rehabilitation Medicine, Rehabilitation in Health Research Group, University of Antioquia, Medellin, Colombia
| | - Michael S Xu
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Linda Grüßer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sapna Humar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amabelle A Moreno
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Division of Pediatric Surgery, Department of Surgery, University of the Philippines-Philippine General Hospital, Manila, The Philippines
| | - Marvee Turk
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Koushik Kasanagottu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michael A Ko
- Division of Thoracic Surgery, Department of Surgery, St. Joseph's Health Centre, University of Toronto, Toronto, ON, Canada
| | | | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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12
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Tupper HI, Roybal BO, Jackson RW, Banks KC, Kwak HV, Alcasid NJ, Wei J, Hsu DS, Velotta JB. The impact of minimally-invasive esophagectomy operative duration on post-operative outcomes. Front Surg 2024; 11:1348942. [PMID: 38440416 PMCID: PMC10909993 DOI: 10.3389/fsurg.2024.1348942] [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: 12/03/2023] [Accepted: 02/07/2024] [Indexed: 03/06/2024] Open
Abstract
Background Esophagectomy, an esophageal cancer treatment mainstay, is a highly morbid procedure. Prolonged operative time, only partially predetermined by case complexity, may be uniquely harmful to minimally-invasive esophagectomy (MIE) patients for numerous reasons, including anastomotic leak, tenuous conduit perfusion and protracted single-lung ventilation, but the impact is unknown. This multi-center retrospective cohort study sought to characterize the relationship between MIE operative time and post-operative outcomes. Methods We abstracted multi-center data on esophageal cancer patients who underwent MIE from 2010 to 2021. Predictor variables included age, sex, comorbidities, body mass index, prior cardiothoracic surgery, stage, and neoadjuvant therapy. Outcomes included complications, readmissions, and mortality. Association analysis evaluated the relationship between predictor variables and operative time. Multivariate logistic regression characterized the influence of potential predictor variables and operative time on post-operative outcomes. Subgroup analysis evaluated the association between MIE >4 h vs. ≤4 h and complications, readmissions and survival. Results For the 297 esophageal cancer patients who underwent MIE between 2010 and 2021, the median operative duration was 4.8 h [IQR: 3.7-6.3]. For patients with anastomotic leak (5.1%) and 1-year mortality, operative duration was elevated above the median at 6.3 h [IQR: 4.8-8.6], p = 0.008) and 5.3 h [IQR: 4.4-6.8], p = 0.04), respectively. In multivariate logistic regression, each additional hour of operative time increased the odds of anastomotic leak and 1-year mortality by 39% and 19%, respectively. Conclusions Esophageal cancer is a poor prognosis disease, even with optimal treatment. Operative efficiency, a modifiable surgical variable, may be an important target to improve MIE patient outcomes.
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Affiliation(s)
- Haley I. Tupper
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Belia O. Roybal
- Division of Research, Biostatistical Consulting Unit, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Riley W. Jackson
- UCSF School of Medicine, University of California, San Francisco, CA, United States
| | - Kian C. Banks
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
- Division of General Surgery, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, United States
| | - Hyunjee V. Kwak
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
- Division of General Surgery, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, United States
| | - Nathan J. Alcasid
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
- Division of General Surgery, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, United States
| | - Julia Wei
- Division of Research, Biostatistical Consulting Unit, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Diana S. Hsu
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
- Division of General Surgery, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, United States
| | - Jeffrey B. Velotta
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, Oakland, CA, United States
- UCSF School of Medicine, University of California, San Francisco, CA, United States
- Division of Clinical Medicine, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
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13
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Hsiao WL, Hung WT, Yang CH, Lai YH, Kuo SW, Liao HC. Effects of high flow nasal cannula following minimally invasive esophagectomy in ICU patients: A prospective pre-post study. J Formos Med Assoc 2023; 122:1247-1254. [PMID: 37280137 DOI: 10.1016/j.jfma.2023.05.016] [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: 12/26/2022] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND/PURPOSE Patients with esophageal cancer who undergo minimally invasive esophagectomy are at risk of postoperative pulmonary complications. High-flow nasal cannula oxygen therapy delivers humidified, warmed positive airway pressure but has not been applied routinely after surgery. Here, we aimed to compare high-flow nasal cannula and conventional oxygen therapy in patients with esophageal cancer during intensive care unit hospitalization 48 h postoperatively. METHODS In this prospective pre- and post-intervention study, patients with esophageal cancer who underwent elective minimally invasive esophagectomy (MIE) and were extubated in the operation room and admitted to the intensive care unit postoperatively were assigned to receive either high-flow nasal cannula (HFNCO) or standard oxygen (SO) therapy. Participants in the SO group were recruited before January 2020, and those in the HFNCO group were enrolled after January 2020. The primary outcome was the difference in postoperative pulmonary complication incidence. Secondary outcomes were the occurrence of desaturation within 48 h, PaO2/FiO2 within 48 h, anastomotic leakage, length of intensive care unit and hospital stay, and mortality. RESULTS The standard oxygen and high-flow nasal cannula oxygen groups comprised 33 and 36 patients, respectively. Baseline characteristics were comparable between groups. In the HFNCO group, postoperative pulmonary complication incidence was significantly reduced (22.2% vs 45.5%) and PaO2/FiO2 was significantly increased. No other between-group differences were observed. CONCLUSION HFNCO therapy significantly reduced postoperative pulmonary complication incidence after elective MIE in patients with esophageal cancer without increasing the risk of anastomotic leakage.
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Affiliation(s)
- Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ting Hung
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chen-Hao Yang
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yeur-Hur Lai
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Cancer Center Taipei, Taiwan
| | - Shuenn-Wen Kuo
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hsien-Chi Liao
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
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14
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Klarenbeek BR, Fujiwara H, Scholte M, Rovers M, Shiozaki A, Rosman C. Introduction of Minimally Invasive transCervical oEsophagectomy (MICE) according to the IDEAL framework. Br J Surg 2023; 110:1096-1099. [PMID: 36960594 PMCID: PMC10416700 DOI: 10.1093/bjs/znad079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/03/2023] [Accepted: 02/21/2023] [Indexed: 03/25/2023]
Affiliation(s)
| | - Hitoshi Fujiwara
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Mirre Scholte
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Maroeska Rovers
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Atsushi Shiozaki
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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15
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Kita R, Kobayashi H, Kondo M, Kaihara S. Impact of intravenous injection of glucagon on anastomotic leakage in esophagectomy. Heliyon 2023; 9:e16442. [PMID: 37292332 PMCID: PMC10245153 DOI: 10.1016/j.heliyon.2023.e16442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/04/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
Background Anastomotic leakage after esophagectomy affects the early postoperative state and prognosis. However, effective measures to prevent anastomotic leakage in esophagogastric anastomosis have not been established. Methods This single-center, retrospective, observational study included 147 patients who underwent esophagectomy for esophageal cancer between 2010 and 2020. Glucagon was administered to extend the gastric tube in patients who underwent esophagectomy from January 2016. The patients were divided into two groups: a glucagon-treated group (2016-2020) and a control group (2010-2015). The incidence of anastomotic leakage was compared between the two groups for evaluation of the preventive effects of glucagon administration on anastomotic leakage. Results The length of the gastric tube from the pyloric ring to the final branch of the right gastroepiploic artery was extended by 2.8 cm after glucagon injection. The incidence of anastomotic leakage was significantly lower in the glucagon-treated group (19% vs. 38%; p = 0.014). Multivariate analysis showed that glucagon injection was the only independent factor associated with a reduction in anastomotic leakage (odds ratio, 0.26; 95% confidence interval, 0.07-0.87). Esophagogastric anastomosis was performed proximal to the final branch of the right gastroepiploic artery in 37% patients in the glucagon-treated group, and these cases showed a lower incidence of anastomotic leakage than did those with anastomosis distal to the final branch of the right gastroepiploic artery (10% vs. 25%, p = 0.087). Conclusions Extension of the gastric tube by intravenous glucagon administration during gastric mobilization in esophagectomy for esophageal cancer may be effective in preventing anastomotic leakage.
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Affiliation(s)
- Ryosuke Kita
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
- Department of Gastrointestinal Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Kobayashi
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Masato Kondo
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
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16
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Abstract
OBJECTIVE To determine the effect of prolonged length of stay (LOS) after esophagectomy on long term survival. BACKGROUND Complications after esophagectomy have a significant impact in short-term survival. The specific effect of prolonged LOS after esophagectomy is unclear. We hypothesized that postoperative complications that occur after esophagectomy, resulting in prolonged LOS, have a detrimental effect on long term survival. METHODS All patients undergoing esophagectomy between 2004 and 2014 were identified in the National Cancer Database. To eliminate the confounding effect of short-term mortality, we included only patients who survived at least 90 days postoperatively. Demographics, disease characteristics, and perioperative outcomes were analyzed. Postoperative LOS was used as a surrogate for postoperative complications. The highest quintile of LOS was defined as excessive LOS (ELOS). Kaplan-Meier and Cox proportional hazards survival analyses were performed to examine survival. RESULTS A total of 20,719 patients were identified. Of those 3826 had ELOS, with median LOS 26days (range 18-168days). Their median survival was 30.6 months compared to 53.6 months in the entire non-ELOS group (P < 0.0001). After multivariate analysis ELOS (odds ratio 1.56, 95% confidence interval 1.46-1.67) was an independent predictor of overall mortality. Higher disease stage, higher age, male sex, higher Charlson/Deyo comorbidity score, and readmission after discharge were also significant negative predictors of long-term survival, whereas surgery in an academic institution, being at the highest income quartile and having private or Medicare insurance predicted longer survival (all P < 0.001). CONCLUSIONS AND RELEVANCE Postoperative complications after esophagectomy, resulting in ELOS, predict lower long-term survival independent of other factors. Counseling patients about surgery should include the detrimental long-term effects of postoperative complications and ELOS. Avoiding ELOS (LOS exceeding 18 days) could be considered a quality metric after esophagectomy.
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17
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Zhang W, Cui D, Shi K, Chen M, Zhang B, Qian R. Feasibility and safety of expandable mediastinoscopic and laparoscopic radical esophagectomy. Front Oncol 2023; 13:1110962. [PMID: 37152019 PMCID: PMC10154627 DOI: 10.3389/fonc.2023.1110962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Background At present, minimally invasive radical esophagectomy is the main surgical method for esophageal cancer treatment, but it has inherent limitations. We have developed a novel method of radical esophagectomy without thoracotomy to improve this situation, namely, by using EMLE. We evaluated the feasibility and safety of expandable mediastinoscopic and laparoscopic radical esophagectomy (EMLE) through a retrospective analysis. Methods From January 2019 to June 2022, we successfully performed 106 cases of radical resection of esophageal cancer with this new surgical technique, gradually improved the surgical path, and recorded the perioperative data and postoperative complications of all patients. Results The operation was successfully performed in all patients except for two patients who required a switch to open surgery. The mean operation time was 171.11 ± 33.29 min and the mean intraoperative blood loss was 93.53 ± 56.32 ml. The mean number of removed lymph nodes was 23.59 ± 5.42. The postoperative complications included pneumonia (3.77%), recurrent laryngeal nerve palsy (1.89%), anastomotic leak (14.15%), pleural effusion (5.66%), chylothorax (2.83%), and reoperation (4.72%). All complications were graded I-III per the Clavien-Dindo classification. No perioperative death was recorded. Conclusion Expandable mediastinoscopic and laparoscopic radical esophagectomy is feasible for radical resection of esophageal cancer, with good therapeutic effect and safety. Because of its minimal impact on patients and convenient operation, it is a novel surgical option for patients with esophageal cancer and is expected to become a standard surgical method for radical esophagectomy in the future.
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Affiliation(s)
- Weidong Zhang
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
| | - Dong Cui
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
| | - Kefeng Shi
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
| | - Maolin Chen
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
| | - Binbin Zhang
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
| | - Rulin Qian
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, Henan, China
- Henan Provincial Mediastinoscope Diagnosis and Treatment Center, Zhengzhou, Henan, China
- *Correspondence: Rulin Qian,
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18
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Perioperative Decrease in Tongue Pressure is an Intervenable Predictor of Aspiration After Esophagectomy. Dysphagia 2022:10.1007/s00455-022-10541-2. [DOI: 10.1007/s00455-022-10541-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/14/2022] [Indexed: 12/05/2022]
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Risk factors for refractory enterocutaneous fistula following button jejunostomy removal and its treatment using a novel extraperitoneal approach in patients with oesophageal cancer: a retrospective cohort study. BMC Gastroenterol 2022; 22:486. [PMID: 36434536 PMCID: PMC9700890 DOI: 10.1186/s12876-022-02524-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Enterocutaneous fistula after removal of the jejunostomy tube leads to multiple problems, such as cosmetic problems, decreased quality of life, electrolyte imbalances, infectious complications, and increased medical costs. However, the risk factors for refractory enterocutaneous fistula (REF) after button jejunostomy removal remain unclear. Therefore, in this study, we assessed the risk factors for REF after button jejunostomy removal in patients with oesophageal cancer and reported the surgical outcomes of the novel extraperitoneal approach (EPA) for REF closure. METHODS This retrospective cohort study included 47 patients who underwent button jejunostomy removal after oesophagectomy for oesophageal cancer. We assessed the risk factors for REF in these patients and reported the surgical outcomes of the novel EPA for REF closure at the International University of Health and Welfare Hospital between March 2013 and October 2021. The primary endpoint was defined as the occurrence of REF after removal of the button jejunostomy, which was assessed using a maintained database. The risk factors and outcomes of the EPA for REF closure were retrospectively analysed. RESULTS REFs occurred in 15 (31.9%) patients. In the univariate analysis, REF was significantly more common in patients with albumin level < 4.0 g/dL (p = 0.026), duration > 12 months for button jejunostomy removal (p = 0.003), and with a fistula < 15.0 mm (p = 0.002). The multivariate analysis revealed that a duration > 12 months for button jejunostomy removal (odds ratio [OR]: 7.15; 95% confidence interval [CI]: 1.38-36.8; p = 0.019) and fistula < 15.0 mm (OR: 8.08; 95% CI: 1.50-43.6; p = 0.002) were independent risk factors for REF. EPA for REF closure was performed in 15 patients. The technical success rate of EPA was 88.2%. Of the 15 EPA procedures, fistula closure was achieved in 12 (80.0%). The complications of EPA (11.7%) were major leakages (n = 3) and for two of them, EPA procedure was re-performed, and closure of the fistula was finally achieved. CONCLUSION This study suggested that duration > 12 months for button jejunostomy removal and fistula < 15.0 mm are the independent risk factors for REF after button jejunostomy removal. EPA for REF closure is a novel, simple, and useful surgical option for patients with REF after oesophagectomy.
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20
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Hayes M, Gillman A, Wright B, Dorgan S, Brennan I, Walshe M, Donohoe C, Reynolds JV, Regan J. Prevalence, nature and trajectory of dysphagia postoesophageal cancer surgery: a prospective longitudinal study protocol. BMJ Open 2022; 12:e058815. [PMID: 36137623 PMCID: PMC9511601 DOI: 10.1136/bmjopen-2021-058815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Dysphagia is a common problem following oesophagectomy, and is associated with aspiration pneumonia, malnutrition, weight loss, prolonged enteral feeding tube dependence, in addition to an extended in-hospital stay and compromised quality of life (QOL). To date, the prevalence, nature and trajectory of post-oesophagectomy dysphagia has not been systematically studied in a prospective longitudinal design. The study aims (1) to evaluate the prevalence, nature and trajectory of dysphagia for participants undergoing an oesophagectomy as part of curative treatment, (2) to determine the risk factors for, and post-operative complications of dysphagia in this population and (3) to examine the impact of oropharyngeal dysphagia on health-related QOL across time points. METHODS AND ANALYSIS A videofluoroscopy will be completed and analysed on both post-operative day (POD) 4 or 5 and at 6-months post-surgery. Other swallow evaluations will be completed preoperatively, POD 4 or 5, 1-month and 6-month time points will include a swallowing screening test, tongue pressure measurement, cough reflex testing and an oral hygiene evaluation. Nutritional measurements will include the Functional Oral Intake Scale to measure feeding tube reliance, Malnutrition Screening Tool and the Strength, Assistance With Walking, Rise From a Chair, Climb Stairs and Falls questionnaire. The Reflux Symptom Index will be administered to investigate aerodigestive symptoms commonly experienced by adults post-oesophagectomy. Swallowing-related QOL outcome measures will be determined using the European Organisation for Research and Treatment of Cancer QLQ-18, MD Anderson Dysphagia Inventory and the Swallowing Quality of Life Questionnaire. ETHICS AND DISSEMINATION Ethical approval has been granted by the Tallaght University Hospital/St. James' Hospital Research Ethics Committee (JREC), Dublin, Ireland (Ref. No. 2021-Jul-310). The study results will be published in peer-reviewed journals and presented at national and international scientific conferences.
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Affiliation(s)
- Michelle Hayes
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
- Senior Upper GI and ICU Speech and Language Therapist, St. James's Hospital, Dublin, Ireland
| | - Anna Gillman
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Brona Wright
- Patient and Public Representative Group, Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Sean Dorgan
- Patient and Public Representative Group, Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Ian Brennan
- Department of Radiology, St. James's Hospital, Dublin, Ireland
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Claire Donohoe
- Consultant Gastrointestinal Surgeon, Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - John V Reynolds
- Consultant Gastrointestinal Surgeon, Department of Surgery, St. James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
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21
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A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial. Int J Surg 2022; 106:106921. [PMID: 36116675 DOI: 10.1016/j.ijsu.2022.106921] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.
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22
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Laurent A, Marechal R, Farinella E, Bouazza F, Charaf Y, Gay F, Van Laethem JL, Gonsette K, El Nakadi I. Esophageal cancer: Outcome and potential benefit of esophagectomy in elderly patients. Thorac Cancer 2022; 13:2699-2710. [PMID: 36000335 PMCID: PMC9527164 DOI: 10.1111/1759-7714.14596] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background This analysis evaluated the morbimortality and the potential benefit of esophagectomy for cancer in elderly patients. Methods Patients who underwent esophagectomy for EC were divided into elderly (≥70 years) and nonelderly (<70 years) groups. The groups were compared regarding patient and tumor characteristics, postoperative morbimortality, and disease‐free, overall and cancer‐specific survival. Results Sixty‐one patients were classified into elderly, and 187 into nonelderly groups. The elderly were characterized by a higher rate of WHO score (p < 0.0001), higher cardiac (p < 0.004) and renal (p < 0.023) comorbidities. The rate of neoadjuvant therapy and especially of neoadjuvant CRT was significantly lower in elderly patients (p < 0.018 and p < 0.007). Operative morbidity was also higher in this group (p < 0.024). The 30‐ and 90‐day mortality was 8.2 and 11.5%, respectively in elderly patients and 0.5 and 3.2% in nonelderly patients (p < 0.004 and p < 0.012). This 90‐day mortality decreased when specific surgery‐related deaths were taken into consideration. OS and DFS were significantly better in the nonelderly group (p < 0.003 and p < 0.005) while no difference was observed for cancer‐specific survival (CSS). Conclusion No difference in CSS was observed. Although elderly patients with EC had higher postoperative morbimortality, the age should not be a criterion whether to perform, or not to perform, esophagectomy. This decision must be based on the balance between the patient's general condition and aggressive disease.
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Affiliation(s)
- Adeline Laurent
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Raphael Marechal
- Department of Gastroenterology, University Hospital Center of Tivoli, La louvière, Belgium
| | - Eleonora Farinella
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Fikri Bouazza
- Department of Digestive Surgical Oncology, Faculty of Medicine (ULB), Institut Jules Bordet, Brussels, Belgium
| | - Yassine Charaf
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - France Gay
- Department of Gastroenterology and Digestive Oncology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology and Digestive Oncology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Kimberly Gonsette
- Department of Anesthesiology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Issam El Nakadi
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
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23
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Noshiro H, Okuyama K, Kajiwara S, Yoda Y, Ikeda O. Initial Learning Curve and Stereotypical Use of Extra Arm During da Vinci Chest Procedures of McKeown Esophagectomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:324-332. [PMID: 35929815 DOI: 10.1177/15569845221115237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: McKeown esophagectomy facilitates extensive lymphadenectomy for the optimal management of esophageal cancer. Robot-assisted esophagectomy (RAE) was introduced in an attempt to reduce the incidence of postoperative complications. The da Vinci System has 3 active robotic arms in addition to the camera scope, and an extra robotic arm (ERA) is generally used to maintain a fine and stable operative field. However, the optimal use of an ERA has not been documented. In addition, the learning curve of the RAE using the da Vinci System remains controversial. In this study, we aimed to determine the optimal use of an ERA in association with the initial learning curve of robotic McKeown esophagectomy with extremely extensive lymphadenectomy. Methods: We reviewed 81 consecutive patients who underwent RAE. To determine whether stereotypical use of an ERA after establishment of its optimal use accounted for the learning curve, we measured the duration of 14 steps and the duration when performed with optimal use of an ERA in the corresponding step by reviewing video-recorded procedures. We then calculated the ratio as the degree of stereotypical use of the ERA during the da Vinci chest procedures. Results: The cumulative sum method showed that the learning curve required 27 cases of RAE. In addition, stereotypical use of the ERA was significantly associated with the learning curve of RAE. Conclusions: Establishment of optimal use of an ERA could help to accelerate the learning curve in da Vinci chest procedures during McKeown esophagectomy with extensive lymphadenectomy.
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Affiliation(s)
- Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, 13030Saga University, Japan
| | - Keiichiro Okuyama
- Department of Surgery, Faculty of Medicine, 13030Saga University, Japan
| | - Shuhei Kajiwara
- Department of Gastroenterological Surgery, Saga Medical Centre Koseikan, Japan
| | - Yukie Yoda
- Department of Surgery, Faculty of Medicine, 13030Saga University, Japan
| | - Osamu Ikeda
- Department of Gastroenterological Surgery, Saga Medical Centre Koseikan, Japan
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24
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Holleran TJ, Napolitano MA, Sparks AD, Antevil JL, Brody FJ, Trachiotis GD. Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System. J Surg Res 2022; 275:291-299. [DOI: 10.1016/j.jss.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/08/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
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25
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Esagian SM, Ziogas IA, Skarentzos K, Katsaros I, Tsoulfas G, Molena D, Karamouzis MV, Rouvelas I, Nilsson M, Schizas D. Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:3177. [PMID: 35804949 PMCID: PMC9264782 DOI: 10.3390/cancers14133177] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/12/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023] Open
Abstract
Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): -187.08 mL, 95% CI: [-283.81, -90.35]) and shorter hospital stays (WMD: -9.22 days, 95% CI: [-14.39, -4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.
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Affiliation(s)
- Stepan M. Esagian
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Ioannis A. Ziogas
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Konstantinos Skarentzos
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Ioannis Katsaros
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115-27 Athens, Greece
| | - Georgios Tsoulfas
- First Department of Surgery, Aristotle University of Thessaloniki, 541-24 Thessaloniki, Greece;
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Michalis V. Karamouzis
- Molecular Oncology Unit, Department of Biological Chemistry, National and Kapodistrian University of Athens, 115-27 Athens, Greece;
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden; (I.R.); (M.N.)
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden; (I.R.); (M.N.)
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115-27 Athens, Greece
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Plat VD, Stam WT, Bootsma BT, Straatman J, Klausch T, Heineman DJ, van der Peet DL, Daams F, Dutch Upper GI Cancer Audit Group. Short-term outcome for high-risk patients after esophagectomy. Dis Esophagus 2022; 36:6611914. [PMID: 35724560 PMCID: PMC9817823 DOI: 10.1093/dote/doac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 02/14/2022] [Indexed: 01/11/2023]
Abstract
Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.
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Affiliation(s)
- Victor D Plat
- Address correspondence to: V.D. Plat, MD, Amsterdam University Medical Centers, VU University Medical center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Wessel T Stam
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klausch
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - David J Heineman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands,Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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Choi YK, Noh JH, Kim DH, Na HK, Ahn JY, Lee JH, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY. Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis. Clin Endosc 2022; 55:381-389. [PMID: 35656629 PMCID: PMC9178137 DOI: 10.5946/ce.2021.242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/10/2022] [Indexed: 11/14/2022] Open
Abstract
Background/Aims The treatment of superficial esophageal neoplasms (SENs) in cirrhotic patients is challenging and rarely investigated. We evaluated the outcomes of endoscopic submucosal dissection (ESD) to determine the efficacy and safety of treating SENs in patients with liver cirrhosis.
Methods The baseline characteristics and treatment outcomes of patients who underwent ESD for SENs between November 2005 and December 2017 were retrospectively reviewed.
Results ESD was performed in 437 patients with 481 SENs, including 15 cirrhotic patients with 17 SENs. En bloc resection (88.2% vs. 97.0%) and curative resection (64.7% vs. 78.9%) rates were not different between the cirrhosis and non-cirrhosis groups (p=0.105 and p=0.224, respectively). Bleeding was more common in cirrhotic patients (p=0.054), and all cases were successfully controlled endoscopically. The median procedure and hospitalization duration did not differ between the groups. Overall survival was lower in cirrhotic patients (p=0.003), while disease-specific survival did not differ between the groups (p=0.85).
Conclusions ESD could be a safe and effective treatment option for SENs in patients with cirrhosis. Detailed preprocedural assessments are needed, including determination of liver function, esophageal varix status, and remaining life expectancy, to identify patients who will obtain the greatest benefit.
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Affiliation(s)
- Young Kwon Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence: Do Hoon Kim Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea E-mail:
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chen Z, Huang K, Wei R, Liu C, Fang Y, Wu B, Xu Z, Ding X, Tang H. Transcervical inflatable mediastinoscopic esophagectomy versus thoracoscopic esophagectomy for local early‐ and intermediate‐stage esophageal squamous cell carcinoma: A propensity score‐matched analysis. J Surg Oncol 2022; 125:839-846. [PMID: 35066884 PMCID: PMC9304140 DOI: 10.1002/jso.26798] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 01/31/2023]
Abstract
Background and objective Transcervical inflatable mediastinoscopic esophagectomy (TIME) is a novel method of minimally invasive esophagectomy (MIE) for esophageal cancer. However, whether TIME is effective and feasible as conventional MIE remains unclear. This study aimed to evaluate the efficacy of TIME by comparing it with thoracoscopic esophagectomy (TE). Methods Surgical outcomes and relapse‐free survival (RFS) rates of patients with local early‐ or intermediate‐stage thoracic esophageal squamous cell carcinoma that underwent TIME or TE from January 2017 to December 2019 were analyzed in this retrospective study. Propensity score matching was used to control the confounding factors. Results The mean operation time in TIME was shorter than that in TE (p < 0.05). Patients in the TIME group achieved postoperative ambulation earlier than those in the TE group (p < 0.05). The rate of pulmonary complications was lower in TIME than in TE (p < 0.05). The number of lymph nodes harvested during surgery and the RFS rates of two groups did not have significant differences. Conclusion TIME may be a feasible and safe method to treat local early‐ and intermediate‐stage thoracic esophageal squamous cell carcinoma effectively and it could be a supplementary surgical method of TE for patients with poor pulmonary function or cannot undergo TE.
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Affiliation(s)
- Zihao Chen
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Kenan Huang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Rongqiang Wei
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Chengdong Liu
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Yunhao Fang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Bin Wu
- Department of Thoracic Surgery Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Zhifei Xu
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Xinyu Ding
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
| | - Hua Tang
- Department of Minimally Invasive Thoracic Surgery Center Second Affiliated Hospital of Naval Medical University Shanghai China
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Pulmonary Risk Assessment. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Tukanova KH, Chidambaram S, Guidozzi N, Hanna GB, McGregor AH, Markar SR. Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 29:3148-3167. [PMID: 34961901 PMCID: PMC8990957 DOI: 10.1245/s10434-021-11122-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/11/2021] [Indexed: 12/30/2022]
Abstract
Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. Objective The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. Methods An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). Results Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. Conclusion This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-11122-7.
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Affiliation(s)
- Karina H Tukanova
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Nadia Guidozzi
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alison H McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK. .,Nuffield Department of Surgery, University of Oxford, Oxford, UK. .,Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden. .,Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, London, UK.
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31
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Carr RA, Harrington C, Stella C, Glauner D, Kenny E, Russo LM, Garrity MJ, Bains MS, Sihag S, Jones DR, Molena D. Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer. Cancer Med 2021; 11:592-601. [PMID: 34935304 PMCID: PMC8817095 DOI: 10.1002/cam4.4360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 11/11/2022] Open
Abstract
Background Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients. Methods We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded. Results Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups. Conclusions Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.
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Affiliation(s)
- Rebecca A Carr
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caitlin Harrington
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christina Stella
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Diana Glauner
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Erin Kenny
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lianne M Russo
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan J Garrity
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Patel DC, Bhandari P, Shrager JB, Berry MF, Backhus LM, Lui NS, Liou DZ. Perioperative Outcomes After Combined Esophagectomy and Lung Resection. J Surg Res 2021; 270:413-420. [PMID: 34775148 DOI: 10.1016/j.jss.2021.09.037] [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: 03/01/2021] [Revised: 08/27/2021] [Accepted: 09/21/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality. METHODS Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression. RESULTS Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]). CONCLUSIONS Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.
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Affiliation(s)
- Deven C Patel
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Prasha Bhandari
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California; VA Palo Alto Health Care System, Palo Alto, California
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California; VA Palo Alto Health Care System, Palo Alto, California
| | - Leah M Backhus
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California; VA Palo Alto Health Care System, Palo Alto, California
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Douglas Z Liou
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California.
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Zhang B, Wu Z, Wang Q, Pan S, Wang L, Shen G, Chai H, Wu M. The comparisons of three stapler placement methods for intrathoracic mechanistic circular stapling in Ivor Lewis minimally invasive esophagectomy. J Gastrointest Oncol 2021; 12:1973-1984. [PMID: 34790365 PMCID: PMC8576206 DOI: 10.21037/jgo-21-322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/24/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To analyze the impact of the reversal penetrating technique (RPT) for intrathoracic gastroesophageal mechanical anastomosis on the development of anastomotic complications in Ivor Lewis minimally invasive esophagectomy (ILMIE), and to further identify the risk factors for the development of anastomotic leakage and stricture. METHODS A retrospective observational study was conducted using the clinical data of 316 patients with esophageal carcinoma (EC) who underwent ILMIE from January 2012 to December 2019. The participants were divided into three groups, namely the RPT group, the transoral Orvil technique (TOT) group, and the purse-string technique (PST) group, according to the different stapler placement methods for intrathoracic mechanistic circular stapling. Multivariate analysis was performed to investigate the association of risk factors with anastomotic leakage and stricture. RESULTS There were 154 patients in the RPT group, 78 in the TOT group, and 84 in the PST group for intrathoracic gastroesophageal circular stapling in ILMIE. There were no differences in intraoperative anastomosis-related conditions including conversion of open operations, and lymph nodes harvested between the three groups. However, the mean total operative time and gastroesophageal anastomosis time in the RPT group were significantly shorter than those in the other groups (both P<0.05). The rates of anastomotic leakage and stricture showed no statistical differences between the three groups (leakage: P=0.875; stricture: P=0.942). Multivariate analysis revealed that the RPT method of anvil placement did not increase the probability of anastomotic leakage [RPT: reference; TOT: odds ratio (OR) 0.422, P=0.341; PST: OR 1.436, P=0.645] and stricture (RPT: reference; TOT: OR 0.579, P=0.376; PST: OR 1.195, P=0.755). CONCLUSIONS The RPT method of anvil placement for intrathoracic gastroesophageal circular stapling does not increase the risk of anastomotic complications in ILMIE, but had significantly shorter surgical time and anastomosis time.
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Affiliation(s)
- Bo Zhang
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Thoracic Surgery, Taizhou Hospital, School of Medicine, Zhejiang University, Taizhou, China
| | - Zixiang Wu
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qi Wang
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Saibo Pan
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lian Wang
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Gang Shen
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huiping Chai
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ming Wu
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Early intervention of the perioperative multidisciplinary team approach decreases the adverse events during neoadjuvant chemotherapy for esophageal cancer patients. Esophagus 2021; 18:797-805. [PMID: 33999305 DOI: 10.1007/s10388-021-00844-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Multidisciplinary team (MDT) approach has become a standard for perioperative patient care, including in esophageal cancer. In our institution, the Perioperative Management Center (PERiO) has been doing an MDT approach for patients undergoing esophageal cancer surgery since 2009. On the other hand, neoadjuvant therapy has also been becoming standard for many malignancies, including esophageal cancer. In Japan, neoadjuvant chemotherapy (NAC) for esophageal cancer is standard now. However, there have been no reports about when is the best time to start the MDT approach for patients with neoadjuvant therapy. In this study, the best start time for the MDT approach for esophageal cancer patients with NAC was examined from the perspective of adverse events during chemotherapy and perioperative period. METHODS All cases underwent thoracoscopic esophagectomy in the prone position (TEPP) after NAC. The PERiO Intervention group that started before NAC (n = 100) was compared with the PERiO Intervention group that started after NAC (n = 77). Eventually, 54 paired cases were matched by propensity score matching. RESULTS The adverse event rate during chemotherapy, especially oral complications, was significantly decreased in the PERiO Intervention started before the NAC group (P = 0.007). Furthermore, weight loss during the period from chemotherapy to surgery was significantly reduced in the group that started before NAC (P = 0.033). CONCLUSION The MDT approach should be started before NAC in patients undergoing esophageal cancer surgery to prevent adverse events during chemotherapy and provide safe perioperative conditions.
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COVID-19 Pneumonia on Post-Operative Day 2 after Esophagectomy: Performing Esophago-Gastric Junction Cancer Surgery during the SARS-Cov-2 Second Wave. ACTA ACUST UNITED AC 2021; 28:1348-1353. [PMID: 33801652 PMCID: PMC8025810 DOI: 10.3390/curroncol28020128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/22/2021] [Indexed: 01/13/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had a substantial impact on the provision of medical healthcare. Due to an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) transmission, elective surgical treatment has been suspended in many centers. The effects of COVID-19 in the early post-operative period after esophagectomy remains unknown. In this report, we present three cases of patients diagnosed with esophago-gastric junction cancer who were scheduled for elective esophagectomy with a curative intention during second wave of COVID-19 pandemic in a single high-volume tertiary center. Despite all available safety measures, one of the patients developed COVID-19 pneumonia on post-operative day two, leading to an impaired respiratory function and increased pleural fluid collection from the chest tube, resulting in a prolonged time of hospital stay. Finding a good balance between the COVID-19-related perioperative risks and consequences of delaying surgical treatment in patients diagnosed with esophago-gastric cancer is a challenge. In order to achieve the best possible outcome, care must be taken to ensure availability of necessary treatment options and to reduce the risk of SARS-Cov-2 transmission perioperatively.
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Li XK, Hua TT, Zhang C, Xu Y, Wu WJ, Zheng C, Wang GM, Qiang Y, Cong ZZ, Yi J, Shen Y. The ratio of gastric tube length to thorax length: a vital factor affecting leak after esophageal cervical anastomosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:458. [PMID: 33850855 PMCID: PMC8039640 DOI: 10.21037/atm-20-6082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Esophagogastric anastomotic leak (AL) is a severe complication following esophageal resection. This study aims to explore preliminarily whether the ratio of the gastric conduit length to the thorax length can be regarded as a potential prognostic variable for AL, and if so, a cut-off value can be found to divide the patients into distinct risk groups. Methods We retrospectively reviewed the clinical data of 273 patients who underwent esophagectomy. The gastric conduit length, the thorax length, and other covariates were collected. Logistic regression was first conducted to probe the rationality of the ratio as a risk indicator of AL. Then the dichotomizing analysis was applied to find the optimal cut-off value. Results The incidence of AL was 12.5% (34/273). The coefficient of the ratio in the logistic regression equation was –7.901 with P<0.001, which indicated that the larger the ratio, the smaller the risk of AL. Further smoothed scatter plots revealed that a potential step function of the ratio of AL incidence exists, of which the steep part ranges from 1.74 to 1.90. Results of the accurate cut-off value search through a minimum P value approach give the optimal dichotomization point of 1.79. Conclusions The ratio of the gastric conduit length to the thorax length can reflect the tension in the anastomosis. The research proposes that surgeons can control the length of the gastric conduit during reconstruction to reduce the tension in the anastomosis and thus lead to a decrease in the incidence of AL.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Tian-Tian Hua
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University, Nanjing, China
| | - Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Gao-Ming Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
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Wang K, Zhong J, Liu Q, Lin P, Fu J. A Propensity Score-Matched Analysis of Thoracolaparoscopic vs Open McKeown's Esophagectomy. Ann Thorac Surg 2021; 113:473-481. [PMID: 33621558 DOI: 10.1016/j.athoracsur.2021.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effectiveness and survival benefit of minimally invasive esophagectomy compared to open esophagectomy (OE) remain controversial. The aim of this study was to evaluate the safety, efficacy, and oncologic outcomes of McKeown's total minimally invasive esophagectomy (tMIE) and McKeown's OE in the treatment of patients with esophageal squamous cell carcinoma. METHODS A series of 917 consecutive patients (306 OE and 611 tMIE) who underwent McKeown's esophagectomy for esophageal squamous cell carcinoma in the Department of Thoracic Surgery at Sun Yat-sen University Cancer Center from January 2011 to December 2016 were evaluated. We performed propensity matching between the tMIE and OE groups on the basis of estimated propensity scores for each patient. RESULTS After propensity-matched analysis, 288 patients were selected from each group. The rate of postoperative complications, such as pneumonia, respiratory insufficiency, cervical anastomotic leakage, and wound infection, in the OE group was significantly higher than that in the tMIE group. Intraoperative blood loss and operative duration were not significantly different between the matched groups, whereas the tMIE group had a shorter length of intensive care unit stay and postoperative hospital stay than the OE group. The R0 resection rate and the number of lymph nodes harvested were not significantly different between groups. There was no significant difference in median overall survival between the 2 groups after matching. CONCLUSIONS McKeown's tMIE was shown to be a safe and effective procedure with long-term survival comparable to that of OE for the patients with esophageal squamous cell carcinoma.
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Affiliation(s)
- Kexi Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou City, China; State Key Laboratory of Oncology in South China, Guangzhou City, China
| | - Jian Zhong
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou City, China; State Key Laboratory of Oncology in South China, Guangzhou City, China
| | - Qianwen Liu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou City, China; State Key Laboratory of Oncology in South China, Guangzhou City, China; Guangdong Esophageal Cancer Institute, Guangzhou City, China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou City, China; State Key Laboratory of Oncology in South China, Guangzhou City, China; Guangdong Esophageal Cancer Institute, Guangzhou City, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou City, China; State Key Laboratory of Oncology in South China, Guangzhou City, China; Guangdong Esophageal Cancer Institute, Guangzhou City, China.
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Yeheyis ET, Kassa S, Yeshitela H, Bekele A. Intraoperative hypotension is not associated with adverse short-term postoperative outcomes after esophagectomy in esophageal cancer patients. BMC Surg 2021; 21:1. [PMID: 33388031 PMCID: PMC7777395 DOI: 10.1186/s12893-020-01015-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/14/2020] [Indexed: 01/02/2023] Open
Abstract
Background The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied. Methods A prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastric anastomosis for esophageal cancer. Intraoperative hypotension (IOH), defined as systolic blood pressure (SBP) < 90 mm Hg lasting more than 5 min, was recorded. Patients’ 30 days post-operative composite outcome of mortality, anastomotic leak, and prolonged hospital stay were analyzed as outcome variables. Result A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. The mean duration of the surgery was 208 min. Intraoperative mean low SBP was 80 mmHg while the lowest record was 55 mmHg. IOH occurred in 51% (n = 29) of patients. Anastomotic leak occurred in 7% (n = 4) (OR 1.2, 95% CI 0.26–6.3; p = 0.76). In-hospital mortality was 5% (n = 3) (OR 1.44, 95% CI 0.22–9.3; p = 0.7) and 33% (n = 18) had prolonged hospital stay (OR 0.53, 95% CI 0.14–1.9; p = 0.34). The overall anastomotic leak rate was 13% (n = 7). Multivariate analysis (logistic regression model) showed SBP < 90 mmHg for more than 5 min was not significantly associated either with individual or composite outcomes of mortality, anastomotic leak, and prolonged hospital stay (AOR 1.06, 95% CI 0.98–1.14; p = 0.16) Conclusion In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association with composite adverse outcomes of mortality, anastomotic leak, and prolonged hospital stay.
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Affiliation(s)
- Ephraim Teffera Yeheyis
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Seyoum Kassa
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hiwot Yeshitela
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebe Bekele
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Groher ME. Iatrogenic Disorders. Dysphagia 2021. [DOI: 10.1016/b978-0-323-63648-3.00008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kidane B, Higgins S, Hirpara DH, Kaaki S, Shen YC, Allison F, Waddell TK, Darling GE. From Emergency Department Visit to Readmission After Esophagectomy: Analysis of Burden and Risk Factors. Ann Thorac Surg 2020; 112:379-386. [PMID: 33310147 DOI: 10.1016/j.athoracsur.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/16/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Frequent emergency department (ED) visits occur after esophagectomy. We aimed to identify the incidence of and risk factors for conversion from ED visit to inpatient admission. METHODS A retrospective cohort study was performed of consecutive esophagectomies at a tertiary Canadian center (1999 to 2014). Multivariable regression analyses identified factors associated with conversion from ED visit to admission. RESULTS There were 520 esophagectomies with 6% inhospital mortality (n = 31). Of those discharged, 29.7% (n = 145) had one or more emergency visit and 43.4% (n = 63) of these patients were readmitted to the hospital. First-time ED visits resulted in inpatient conversion 23.4% of the time (n = 34); successive ED visits resulted in increasing conversion. On multivariable analysis, anastomotic leak (adjusted odds ratio 2.45; 95% confidence interval, 1 to 6.01; P = .05) was independently associated with higher odds of conversion to admission. Sensitivity analysis using Poisson regression to model conversion as a rate identified that living in regions further away was associated with lower conversion rate to admission (risk ratio 0.35; 95% confidence interval, 0.13 to 0.94; P = .04). CONCLUSIONS Although postesophagectomy ED utilization is high, the majority of visits do not convert to admission. With each increasing ED visit, likelihood of converting to admission increases. Anastomotic leakage was associated with higher odds of conversion to admission, possibly related to development of strictures. Access to urgent outpatient endoscopy may help reduce the incidence of ED visits and admission. Although living in regions further away is associated with lower conversion rates to admission at the index hospital, that may be due to patients utilizing closer local hospitals.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Sean Higgins
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dhruvin H Hirpara
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Suha Kaaki
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yu Cindy Shen
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frances Allison
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Hybrid esophagectomy for oesophageal cancer: long-term results. A single-centre experience. Wideochir Inne Tech Maloinwazyjne 2020; 16:297-304. [PMID: 34136024 PMCID: PMC8193741 DOI: 10.5114/wiitm.2020.100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction The authors report long-term outcomes in patients who received neoadjuvant chemoradiotherapy and consequently underwent hybrid oesophagectomy for oesophageal cancer (OC). Aim To evaluate long-term outcomes in patients suffering from OC, who underwent hybrid oesophagectomy. Material and methods Our cohort consisted of patients suffering from OC, who received neoadjuvant chemoradiotherapy. Hybrid esophagectomy was performed 8–10 weeks after oncological treatment. Results Ninety-four patients underwent surgery for OC from 2011 to 2015. Histology revealed adenocarcinoma in 60.6%, squamous cell carcinoma (SCC) in 36.2%, and other type of cancer in 3.2%. Seventy-three (77.7%) patients with advanced stage (T3-4, N0-2, M0) were indicated to receive neoadjuvant chemoradiotherapy (nCRT). Trans-hiatal hybrid oesophagectomy was performed in 83 (88.3%) patients. Transthoracic hybrid oesophagectomy was performed in 11 (11.7%) patients. Histology of the resected specimens of 18 (24.7%) patients did not reveal OC, i.e. pathological complete response (pCR). In our cohort, we proved an association between occurrence of pCR and age as well as disease-free survival (DFS). The patients who presented with pCR were significantly younger – below 60 years of age (p = 0.017). They also showed significantly higher mean DFS (p = 0.004). Conclusions Combined oesophagectomy with neoadjuvant chemoradiotherapy results in a better long-term outcome in patients suffering from oesophageal cancer. In our set of patients who underwent hybrid esophagectomy, satisfactory short-term and especially long-term results of surgical treatment for oesophageal cancer were observed.
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Shirakawa Y, Noma K, Kunitomo T, Hashimoto M, Maeda N, Tanabe S, Sakurama K, Fujiwara T. Initial introduction of robot-assisted, minimally invasive esophagectomy using the microanatomy-based concept in the upper mediastinum. Surg Endosc 2020; 35:6568-6576. [PMID: 33170337 PMCID: PMC7654354 DOI: 10.1007/s00464-020-08154-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
Background We have recently standardized upper mediastinal lymph node dissection (UMLND) using a microanatomy-based concept in thoracoscopic esophagectomy in the prone position (TEPP), and introduced robot-assisted minimally invasive esophagectomy (RAMIE) using the same concept as in TEPP while aiming at solo surgery. The purpose of this study was to investigate the outcomes of RAMIE using the microanatomy-based concept in the initial introduction phase. Methods We have performed more than 500 TEPP procedures as minimally invasive esophagectomy (MIE). After performing about 400 cases of MIE, we established a microanatomy-based standardization of UMLND. In October 2018, we introduced RAMIE, and have performed 75 procedures in 20 months. Two groups were analyzed: a group after microanatomy-based standardization in TEPP (100 cases after completing 400 cases of TEPP) and a RAMIE group (75 cases). Finally, 51 paired cases were matched using a propensity score. Furthermore, the change in postoperative short-term outcome for RAMIE in the initial introduction phase was analyzed. Results Although there were no significant differences between the two groups in the number of upper mediastinal lymph nodes dissected, there was a significant decrease (P = 0.036) in intraoperative blood loss volume with RAMIE, representing a definite benefit for patients. The thoracoscopic operative time for RAMIE decreased by almost 100 min following less than 50 cases of experience, reaching the same level as that for recent TEPP, but with only one-tenth the operator experience. There were no significant differences in the total postoperative morbidity rate including the recurrent laryngeal nerve palsy rate. Conclusion RAMIE has been introduced safely and smoothly using the microanatomy-based concept established in TEPP.
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Affiliation(s)
- Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. .,Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoyoshi Kunitomo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masashi Hashimoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazufumi Sakurama
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Sheill G, Reynolds S, O'Neill L, Mockler D, Reynolds JV, Hussey J, Guinan E. Cardiopulmonary Exercise Testing in Oesophagogastric Surgery: a Systematic Review. J Gastrointest Surg 2020; 24:2667-2678. [PMID: 32632727 DOI: 10.1007/s11605-020-04696-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/07/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery. METHODS Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool. RESULTS Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay. CONCLUSION Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity.
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Affiliation(s)
- G Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - S Reynolds
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - L O'Neill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - D Mockler
- Medical Library, Trinity College Dublin, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, Trinity College Dublin and St. James's Hospital, Dublin, Ireland
| | - J Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - E Guinan
- School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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Kamada T, Ohdaira H, Takeuchi H, Takahashi J, Marukuchi R, Ito E, Suzuki N, Narihiro S, Hoshimoto S, Yoshida M, Urashima M, Suzuki Y. Vertical distance from navel as a risk factor for bowel obstruction associated with feeding jejunostomy after esophagectomy: a retrospective cohort study. BMC Gastroenterol 2020; 20:354. [PMID: 33109092 PMCID: PMC7590660 DOI: 10.1186/s12876-020-01506-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background Placement of feeding jejunostomy (PFJ) during esophagectomy is an effective method to maintain adequate nutrition, but is associated with serious complications such as bowel obstruction and jejunal torsion. The purpose of the current study was to analyze the incidence, clinical features, and risk factors of bowel obstruction associated with feeding jejunostomy (BOFJ) after PFJ. Methods This was a retrospective cohort study of 70 patients who underwent esophagectomy with three-field lymph node dissection for esophageal cancer and treated with PFJ between March 2013 and December 2019 in our hospital. Abdominal dissection was performed under hand-assisted laparoscopic surgery (HALS) from March 2013 to March 2015, and was changed to complete laparoscopic surgery in April 2015. We compared patients with and without BOFJ, and the incidence of BOFJ was evaluated. The primary endpoint was incidence of BOFJ after PFJ. Results Six patients (8.5%) were diagnosed with BOFJ, all of whom were symptomatic and in the HALS group. In addition, 3 cases displayed histories of recurrent BOFJ (3, 3, and 5 times). Laparotomy was performed in all cases. Subgroup analysis of the HALS group showed a significant difference only in straight-line distance between the jejunostomy and navel as a significant pre- and perioperative factor (117 mm [101–130 mm] vs. 89 mm [51–150 mm], p < 0.001). Furthermore, dividing straight-line distance between the jejunostomy and navel into VD and HD, only VD differed significantly (107 mm [93–120 mm] vs. 79 mm [28–135 mm], p = 0.010), not HD (48 mm [40–59 mm] vs. 46 mm [22–60 mm], p = 0.199). Conclusions VD between the jejunostomy and navel was associated with BOFJ after PFJ with HALS esophagectomy. PFJ < 9 cm above the navel during HALS esophagectomy might effectively prevent BOFJ.
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Affiliation(s)
- Teppei Kamada
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan.
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Hideyuki Takeuchi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Junji Takahashi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Rui Marukuchi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Norihiko Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Satoshi Narihiro
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Sojun Hoshimoto
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
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Scholer AJ, Uppal A, Chang SC, Ghosh D, Garland-Kledzik M, Santamaria-Barria J, Khader A, Dehal A, Fischer T, Goldfarb M. Inaccurate pretreatment staging can impact survival in early stage esophageal adenocarcinoma. J Surg Oncol 2020; 122:914-922. [PMID: 32632944 DOI: 10.1002/jso.26101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Given the survival advantage of neoadjuvant treatment for locally advanced esophageal cancer, accurate clinical staging is necessary. The aim of this study was to assess the clinical (c) and pathologic (p) staging concordance rates for presumably early stage esophageal adenocarcinoma patients that had upfront esophagectomy (UFE) and evaluate if survival (OS) was negatively affected by inaccurate preoperative staging and subsequent treatment selection. METHODS An NCDB retrospective review of nonmetastatic esophageal adenocarcinoma patients that had UFE. The rates of concordance between c and p staging system and OS were calculated. RESULTS Of 2775 patients, most patients presented with cN0 (82.8%) and cT1 tumors (53.6%). The overall concordance between c and p staging was 78.8% for T-classification (moderate agreement; weighted κ = 0.729; P < .001) and 78.8% for N-classification (weak agreement; weighted κ = 0.448; P < .001). Patients that were upstaged due to a lack of concordance between T-classification had decreased 5- and 10-year OS (30% and 16%, P < .001) and those upstaged due to discordant N-classification had decreased 5- and 10-year OS (28% and 23%, P < .001)." CONCLUSIONS Preoperative staging of esophageal adenocarcinoma has moderate reliability and accuracy for predicting pT and pN classification. Up to 25% of patients have discordant clinical and pathological staging, which impacts OS.
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Affiliation(s)
- Anthony J Scholer
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
| | - Abhineet Uppal
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
| | - Shu-Ching Chang
- Medical Data Research Center, Providence Health and Services Oregon and Southwest Washington, Portland, Oregon
| | - Debopriya Ghosh
- Rutgers Institute of Data Science, Learning, and Applications, Rutgers University, Newark, New Jersey
| | - Mary Garland-Kledzik
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
| | | | - Adam Khader
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
| | - Ahmed Dehal
- Department of Surgery, Kaiser Permanente Southern California, Pasadena, California
| | - Trevan Fischer
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
| | - Melanie Goldfarb
- Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
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Lu HW, Chen CC, Chen HH, Yeh HL. The clinical outcomes of elderly esophageal cancer patients who received definitive chemoradiotherapy. J Chin Med Assoc 2020; 83:906-910. [PMID: 32889988 PMCID: PMC7526572 DOI: 10.1097/jcma.0000000000000419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) followed by an esophagectomy is the standard treatment for locally advanced esophageal cancer, but remains a great challenge for elderly patients. Therefore, we aim to evaluate the efficacy of definitive CRT in elderly patients with esophageal cancer. METHODS From December 2007 to October 2017, 40 esophageal cancer patients aged ≥70 years receiving definitive CRT were retrospectively analyzed. All patients received cisplatin-based chemotherapy. Ten patients received standard doses of cisplatin 20 mg/m and fluorouracil (5-FU) 800 mg/m for 4 days, during the first and fifth weeks of radiotherapy. Eighteen patients received modified doses of cisplatin 16 to 18 mg/m and 5-FU 600 to 800 mg/m. Twelve patients received lower doses of cisplatin 10 to 12 mg/m and 5-FU 400 to 600 mg/m. The endpoints were overall survival (OS), tumor response rate, and treatment compliance. RESULTS The 3-year OS rate was 28.8% The 3-year OS rates for patients receiving standard, modified, and lower doses were 12.5%, 53.8%, and 0.0%, respectively (p = 0.05). There were 87.5% of patients completing the scheduled radiotherapy dose, along with two cycles of concurrent chemotherapy. The response rate (clinical complete response and partial response rate) was 70.0%. Multivariate analysis revealed that no statistical difference was found in the OS among three groups of chemotherapy dosage. The treatment response was the only independent prognostic factor to OS (p < 0.001). CONCLUSION Definitive CRT with dose modification is a feasible, safe, and reasonable treatment for elderly esophageal cancer patients. Achieving a better compliance to CRT via an optimal dose modification of chemotherapy may provide better clinical outcomes and would be the treatment goal for elderly esophageal cancer patients.
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Affiliation(s)
- Hao-Wei Lu
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chien-Chih Chen
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- PhD Program in Translational Medicine, National Chung-Hsing University, Taichung, Taiwan, ROC
| | - Hsin-Hua Chen
- PhD Program in Translational Medicine, National Chung-Hsing University, Taichung, Taiwan, ROC
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, Chung-Hsing University, Taichung, Taiwan, ROC
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan. ROC
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan, ROC
| | - Hui-Ling Yeh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Address correspondence. Dr. Hui-Ling Yeh, Department of Radiation Oncology, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Taichung 407, Taiwan, ROC. E-mail address: (H.-L. Yeh)
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Yip HC, Shirakawa Y, Cheng CY, Huang CL, Chiu PWY. Recent advances in minimally invasive esophagectomy for squamous esophageal cancer. Ann N Y Acad Sci 2020; 1482:113-120. [PMID: 32783237 DOI: 10.1111/nyas.14461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 12/29/2022]
Abstract
Over the past decade there has been tremendous development in the clinical application of minimally invasive esophagectomy (MIE) for the treatment of squamous esophageal carcinoma. The major challenges in the performance of MIE include limitations in visualization and manipulation within the confined, rigid thoracic cavity; the need for adequate patient positioning and anesthetic techniques to accommodate the surgical exposure; and changes in the surgical steps for achieving radical nodal dissection, especially for the superior mediastinum. The surgical procedure for MIE is more and more standardized, and there is an increasing practice of MIE worldwide. Randomized trials and meta-analyses have confirmed the advantages of MIE over open esophagectomy, including a significantly lower rate of complications and shorter hospital stays. The recent application of robotics technologies for MIE has further enhanced the quality and safety of the surgical dissection, while intraoperative nerve monitoring has contributed to a lower rate of recurrent laryngeal nerve palsy. With the application of new technologies, we expect further improvement in surgical outcomes for MIE in the treatment of squamous esophageal cancer.
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Affiliation(s)
- Hon Chi Yip
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ching-Yuan Cheng
- Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chang-Lun Huang
- Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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Pines G, Jacobson F, Zheng Y, Magali P, Lerut T, Bueno R. Long-Term Radiologic Evaluation of Microaspirations among Patients after Esophagectomy. Thorac Cardiovasc Surg 2020; 69:204-210. [PMID: 32593178 DOI: 10.1055/s-0040-1710579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance. METHODS The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected. RESULTS A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging (n = 51 [42.5%] vs. n = 13 [10.8%] respectively, p < 0.05). Most of these were found in the lower lobes (61%). A higher rate of lesions was found among patients in whom the conduit was bulging to the right hemithorax compared with totally mediastinal or completely in the right hemithorax (54.5 vs. 35.2% and 34.6%, respectively, p < 0.05). No correlation was found with conduit diameter or anastomotic site. These lesions were more prevalent among patients who complained of reflux or cough during meals (NS). CONCLUSIONS A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings.
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Affiliation(s)
- Guy Pines
- Department of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Francine Jacobson
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Yifan Zheng
- Department of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Pham Magali
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Toni Lerut
- Department of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Raphael Bueno
- Department of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
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Matsumoto S, Takayama T, Wakatsuki K, Enomoto K, Tanaka T, Migita K, Ito M, Nakajima Y. Predicting Early Cancer-related Deaths after Curative Esophagectomy for Esophageal Cancer. Am Surg 2020. [DOI: 10.1177/000313481307900530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Esophagectomy is the primary treatment for esophageal cancers, but a few patients still suffer from early recurrence and die within one year after surgery. The aim of this study was to identify preoperative predictive risk factors for early cancer-related deaths after curative esophagectomy for esophageal squamous cell carcinoma. The records of 200 consecutive patients with esophageal cancer who underwent esophagectomy between 1990 and 2009 were retrospectively reviewed. The preoperative clinical characteristics of the remaining 32 patients who died of cancer within one year were compared with those of 168 patients who survived for more than one year postsurgery. The most frequent cause of death was lymph node recurrence followed by local recurrence and lung metastases. A tumor size 60 mm or greater and lymph node metastases in two fields on preoperative imaging were identified as prognostic factors on multivariate analysis. The one-year survival rate and median survival time of patients with both these risk factors were 40 per cent and 12 months, respectively. Aggressive additional treatment may be needed if both a tumor size 60 mm or greater and lymph node metastases in two fields are found during diagnostic imaging before esophagectomy for esophageal squamous cell carcinoma.
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Affiliation(s)
- Sohei Matsumoto
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Tomoyoshi Takayama
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Kohei Wakatsuki
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Koji Enomoto
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Tetsuya Tanaka
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Kazuhiro Migita
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Masahiro Ito
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Yoshiyuki Nakajima
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
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Schweigert M, Solymosi N, Dubecz A, GonzáLez MP, Stein HJ, Ofner D. One Decade of Experience with Endoscopic Stenting for Intrathoracic Anastomotic Leakage after Esophagectomy: Brilliant Breakthrough or Flash in the Pan? Am Surg 2020. [DOI: 10.1177/000313481408000820] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Management of intrathoracic anastomotic leakage after esophagectomy by means of endoscopic stent insertion has gained wide acceptance as an alternative to surgical reintervention. Between January 2004 and March 2013 all patients who underwent esophagectomy at a German high-volume center for esophageal surgery were included in this retrospective study. The study comprises 356 patients. Anastomotic leakage occurred in 49 cases. There were no significant differences in age, American Society of Anesthesiologists (ASA) score, or frequency of neoadjuvant therapy between cases with and without leak. However, leak patients sustained significantly more often postoperative pneumonia, pleural empyema, sepsis, and acute renal failure. Moreover, leak victims had higher odds for fatal outcome (16 of 49 vs 33 of 307; odds ratio, 5.94; 95% confidence interval, 2.65 to 13.15; P < 0.0001). The leakage was amendable by endoscopic stenting in 29 cases, whereas rethoracotomy was mandatory in 20 patients. Between stent and rethoracotomy cases, we observed no significant differences in age, ASA score, neoadjuvant therapy, occurrence of pneumonia, pleural empyema, or tracheostomy rate. Rethoracotomy patients sustained more often sepsis (16 of 20 vs 14 of 29; P = 0.04) and acute renal failure (nine of 20 vs four of 29; P = 0.02) as expression of more severe septic disease. Nevertheless, there was no significant difference in mortality (seven of 29 vs nine of 20; P = 0.21). Furthermore, we observed three cases of stent-related aortic erosion with peracute death from exsanguination. Despite being the preferred treatment option, endoscopic stenting was only feasible in approximately 60 per cent of all intrathoracic leaks. The results are marred by the occurrence of deadly vascular erosion. Therefore, individualized strategies should be preferred to a general recommendation for endoscopic stenting.
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Affiliation(s)
- Michael Schweigert
- Department of Surgery, Klinikum Neumarkt, Neumarkt, Germany; the
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | | | - Attila Dubecz
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | | | - Hubert J. Stein
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | - Dietmar Ofner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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