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Kishimoto Y, Otsuka K, Yamashita T, Saito A, Kohmoto M, Motegi K, Ariyoshi T, Goto S, Murakami M, Aoki T. The correlation between intrathoracic herniation of the gastric tube and postoperative complications and the efficacy of laparoscopic retrosternal route creation. Esophagus 2025; 22:382-389. [PMID: 40108066 PMCID: PMC12167243 DOI: 10.1007/s10388-025-01119-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 03/10/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND Gastric tube prolapse into the thoracic cavity in retrosternal route reconstruction during esophagectomy is known as intrathoracic herniation of the gastric tube (IHGT). However, few reports have determined whether a correlation exists between IHGT and postoperative complications. Moreover, the optimal procedure for avoiding IHGT remains unclear. METHODS This retrospective study included 200 patients who had undergone subtotal esophagectomy and retrosternal gastric tube reconstruction at a single institution. The diagnosis of IHGT was defined as a gastric tube herniation length of ≥ 5 cm on plain chest radiography. The frequency of postoperative complications in patients with IHGT was measured to determine any correlation. The incidence of IHGT in a laparoscopic retrosternal route creation group was also measured and the efficacy of this procedure was investigated. RESULTS The overall incidence of IHGT was 7.5%. The incidence of grade II or higher anastomotic leakage and atelectasis was significantly higher in the IHGT( +) (anastomotic leakage, 26.7% vs. 4.3%, P = 0.007; atelectasis, 40.0% vs. 13.5%, P = 0.016). In univariate analysis, IHGT( +) showed a significantly higher incidence of anastomotic leakage (OR 7.88, P = 0.007). In multivariate analysis, IHGT was an independent risk factor for atelectasis (OR 5.03, P = 0.005). Furthermore, the incidence of IHGT was significantly lower in the laparoscopic group (2.0% vs. 13.0%, P = 0.005). CONCLUSION Our findings show that IHGT may be correlated with grade II or higher anastomotic leakage and atelectasis. Laparoscopic retrosternal route creation may be effective in avoiding IHGT and contributes to a reduction in postoperative complications.
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Affiliation(s)
- Yutaka Kishimoto
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Koji Otsuka
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan.
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan.
| | - Takeshi Yamashita
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Akira Saito
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Masahiro Kohmoto
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Kentaro Motegi
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Tomotake Ariyoshi
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Satoru Goto
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Masahiko Murakami
- Esophageal Cancer Center, Showa University Hospital, 1-5-8, Hatanodai, Sinagawa-ku, Tokyo, 142-8666, Japan
| | - Takeshi Aoki
- Department of Gastrointestinal and General Surgery, School of Medicine, Showa University, Tokyo, Japan
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Zhong QH, Huang JS, Guo FL, Wu JY, Yuan MX, Zhu JF, Lin WW, Chen S, Zhang ZY, Lin JB. Prediction and stratification for the surgical adverse events after minimally invasive esophagectomy: A two-center retrospective study. World J Gastroenterol 2025; 31:101041. [PMID: 39839907 PMCID: PMC11684167 DOI: 10.3748/wjg.v31.i3.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 10/05/2024] [Accepted: 11/25/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) is a widely accepted treatment for esophageal cancer, yet it is associated with a significant risk of surgical adverse events (SAEs), which can compromise patient recovery and long-term survival. Accurate preoperative identification of high-risk patients is critical for improving outcomes. AIM To establish and validate a risk prediction and stratification model for the risk of SAEs in patients with MIE. METHODS This retrospective study included 747 patients who underwent MIE at two centers from January 2019 to February 2024. Patients were separated into a train set (n = 549) and a validation set (n = 198). After screening by least absolute shrinkage and selection operator regression, multivariate logistic regression analyzed clinical and intraoperative variables to identify independent risk factors for SAEs. A risk stratification model was constructed and validated to predict the probability of SAEs. RESULTS SAEs occurred in 10.2% of patients in train set and 13.6% in the validation set. Patients with SAE had significantly higher complication rate and a longer hospital stay after surgery. The key independent risk factors identified included chronic obstructive pulmonary disease, a history of alcohol consumption, low forced expiratory volume in the first second, and low albumin levels. The stratification model has excellent prediction accuracy, with an area under the curve of 0.889 for the training set and an area under the curve of 0.793 for the validation set. CONCLUSION The developed risk stratification model effectively predicts the risk of SAEs in patients undergoing MIE, facilitating targeted preoperative interventions and improving perioperative management.
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Affiliation(s)
- Qi-Hong Zhong
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
- The Graduate School, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Jiang-Shan Huang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Fei-Long Guo
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jing-Yu Wu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Mao-Xiu Yuan
- The Graduate School, Fujian Medical University, Fuzhou 350001, Fujian Province, China
- Department of Thoracic Surgery, Affiliated Hospital of Jinggangshan University, Ji’an 343000, Jiangxi Province, China
| | - Jia-Fu Zhu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Wen-Wei Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Sui Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Zhen-Yang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jiang-Bo Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
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Angus R, Leow TW, Humes D, Adiamah A. The relationship between alcohol consumption and outcomes after gastrointestinal surgery: a systematic review and meta-analysis. Alcohol Alcohol 2025; 60:agaf002. [PMID: 39905807 PMCID: PMC11794451 DOI: 10.1093/alcalc/agaf002] [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: 04/22/2024] [Revised: 12/11/2024] [Accepted: 01/15/2025] [Indexed: 02/06/2025] Open
Abstract
The study aimed to summarise the evidence of the association between preoperative alcohol consumption and postoperative complications in gastrointestinal surgeries. Comprehensive searches of MEDLINE, EMBASE, and Cochrane databases were undertaken to identify original studies investigating the association between preoperative alcohol consumption and postoperative complications occurring within 30 days of surgery. The primary outcome was 30-day mortality risk and secondary outcomes included postoperative complications such as surgical site infections and risk of anastomotic leak. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random effects model. In total, 3601 reports were identified and reviewed for eligibility, then data was extracted from 26 studies that met inclusion criteria. 13 studies were included in the meta-analysis. The total number of patients in the meta-analysis was 686 181 including 20 163 with a high alcohol intake. Clearly defined high preoperative alcohol consumption was associated with an increased risk of postoperative complications including 30-day mortality (OR = 1.56; 95% CI: 1.07-2.28). The risk of anastomotic leak was significantly increased in those undergoing colorectal surgery with a high alcohol intake, OR 2.17 (95% CI: 1.74-2.72). An increase in risk was also found for surgical site infections in those undergoing gastrointestinal surgery with high alcohol intake. (OR = 1.32; 95% CI: 1.15-1.53). Preoperative alcohol consumption was associated with an increased risk of 30-day mortality, anastomotic leak and surgical site infections. Preoperative modulation of alcohol intake may influence post-operative complications after gastrointestinal surgery.
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Affiliation(s)
- Rebecca Angus
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Tjun Wei Leow
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - David Humes
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom
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Harris LB, Vyas V, Marino K, Wells A, Jensen HK, Mavros MN. Mortality and failure-to-rescue after esophagectomy in the procedure-targeted National Surgical Quality Improvement Program registry. World J Surg 2024; 48:2235-2242. [PMID: 39044328 DOI: 10.1002/wjs.12297] [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: 01/15/2024] [Accepted: 07/10/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The association between procedural volume and esophagectomy outcomes has been established, but the relationship between higher levels of care and esophagectomy outcomes has not been explored. This study aims to investigate whether hospital participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) esophagectomy-targeted registry is associated with superior outcomes. METHODS The 2016-2020 ACS NSQIP standard and esophagectomy-targeted registries were queried. Esophagectomy outcomes were analyzed overall and stratified by esophagectomy type (Ivor Lewis vs. transhiatal vs. 3-field McKeown). RESULTS A total of 2181 and 5449 esophagectomy cases were identified in the standard and targeted databases (68% Ivor Lewis esophagectomy). The median age was 65 years and 80% were male. Preoperative characteristics were largely comparable. On univariate analysis, targeted hospitals were associated with lower mortality (2% vs. 4%, p < 0.01) and failure-to-rescue rates (11% vs. 17%, p < 0.01), higher likelihood of an optimal outcome (62% vs. 58%, p = 0.01), and shorter hospital stay (median 9 vs. 10 days, p < 0.01). On multivariable analysis, Ivor Lewis esophagectomy at targeted centers was associated with reduced odds of mortality [odds ratio (OR) 0.57 and 95% confidence intervals 0.35-0.90] and failure-to-rescue [OR 0.54 (0.33-0.90)] with no difference in serious morbidity or optimal outcome. There was no statistically significant difference in odds of mortality or failure to rescue in targeted versus standard centers when performing transhiatal or McKeown esophagectomy. CONCLUSIONS Esophagectomy performed at hospitals participating in the targeted ACS NSQIP is associated with roughly half the risk of mortality compared to the standard registry. The factors underlying this relationship may be valuable in quality improvement.
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Affiliation(s)
- Larkin B Harris
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Vanessa Vyas
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Katy Marino
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Allison Wells
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hanna K Jensen
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michail N Mavros
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Yu B, Liu Z, Zhang L, Pan J, Jiang C, Li C, Li Z. Pre- and intra-operative risk factors predict postoperative respiratory failure after minimally invasive oesophagectomy. Eur J Cardiothorac Surg 2024; 65:ezae107. [PMID: 38492559 DOI: 10.1093/ejcts/ezae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/01/2023] [Accepted: 03/14/2024] [Indexed: 03/18/2024] Open
Abstract
OBJECTIVES Severe pulmonary complications such as postoperative respiratory failure can occur after minimally invasive oesophagectomy. However, the risk factors have not been well identified. The goal of this study was to develop a predictive model for the occurrence of postoperative respiratory failure with a large sample. METHODS We collected data from patients with oesophageal cancer who had a minimally invasive oesophagectomy at Shanghai Chest Hospital from 2019 to 2022. Univariable and backward stepwise logistic regression analysis of 19 pre- and intra-operative factors was used before model fitting, and its performance was evaluated with the receiver operating characteristic curve. Internal validation was assessed with a calibration plot, decision curve analysis and area under the curve with 95% confidence intervals, obtained from 1000 resamples set by the bootstrap method. RESULTS This study enrolled 2,386 patients, 57 (2.4%) of whom developed postoperative respiratory failure. Backward stepwise logistic regression analysis revealed that age, body mass index, cardiovascular disease, diabetes, diffusion capacity of the lungs for carbon monoxide, tumour location and duration of chest surgery ≥101.5 min were predictive factors. A predictive model was constructed and showed acceptable performance (area under the curve: 0.755). The internal validation with the bootstrap method proves the good agreement for prediction and reality. CONCLUSIONS Obesity, severe diffusion dysfunction and upper segment oesophageal cancer were strong predictive factors. The established predictive model has acceptable predictive validity for postoperative respiratory failure after minimally invasive oesophagectomy, which may improve the identification of high-risk patients and enable health-care professionals to perform risk assessment for postoperative respiratory failure at the initial consultation.
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Affiliation(s)
- Boyao Yu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhichao Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Long Zhang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Pan
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao Jiang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunguang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhigang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Beier MA, Greenbaum AA, Kangas-Dick AW, August DA. Does Neoadjuvant Radiation Therapy Contribute to the Incidence of Pulmonary Complications Following Esophagectomy for Malignant Neoplasm? Am Surg 2023; 89:4780-4788. [PMID: 36286615 DOI: 10.1177/00031348221135788] [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] [Indexed: 12/06/2023]
Abstract
BACKGROUND Post-operative pulmonary complications (POPC) are common in patients undergoing esophagectomy and neoadjuvant radiotherapy may exacerbate POPC. This study assessed whether neoadjuvant radiation increases the incidence of POPC in patients undergoing esophagectomy for malignancy. METHODS The American College of Surgeons-National Surgical Quality Improvement Program database files from 2016 to 2018 were queried for patients undergoing esophagectomy for malignancy. Inverse probability treatment weighting (IPTW) was used to create balanced cohorts in which the control group received neoadjuvant chemotherapy (nCT) and the treatment cohort received neoadjuvant chemoradiotherapy (nCRT). A subset analysis was performed on patients with pre-existing pulmonary disease (PEPD). Primary outcomes were POPC and 30-day mortality. RESULTS The all-patient analysis did not demonstrate a consistent association between neoadjuvant radiation and POPC. However, in patients with PEPD, POPC occurred more often in the nCRT cohort. Comparing nCRT to nCT and after IPTW adjustment for confounders, there was higher odds of pneumonia (aOR = 3.0, P = .002), unplanned intubation (aOR = 2.0, P = .03), and extended mechanical ventilation (aOR = 3.6, P = .002). DISCUSSION In esophageal cancer patients with PEPD that undergo nCRT vs nCT prior to esophagectomy, the greater risk of POPCs must be weighed against the potential for improved oncologic outcomes.
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Affiliation(s)
- Matthew A Beier
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alissa A Greenbaum
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Aaron W Kangas-Dick
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Guo X, Ke W, Yang X, Zhao X, Li M. Association of DLT versus SLT with postoperative pneumonia during esophagectomy in China: a retrospective comparison study. BMC Anesthesiol 2023; 23:301. [PMID: 37670237 PMCID: PMC10478392 DOI: 10.1186/s12871-023-02252-4] [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: 06/03/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Double lumen tube (DLT) and single lumen tube (SLT) are two common endotracheal tube (ETT) types in esophageal cancer surgery. Evidence of the relationship between two ETT types and postoperative pneumonia (PP) remains unclear. We aimed to determine the association between two types of ETT (DLT and SLT) and PP and assess the perioperative risk-related parameters that affect PP. METHODS This study included 680 patients who underwent esophageal cancer surgery from January 01, 2010 through December 31, 2020. The primary outcome was PP, and the secondary outcome was perioperative risk-related parameters that affect PP. The independent variable was the type of ETT: DLT or SLT. The dependent variable was PP. To determine the relationship between variables and PP, univariate and multivariate analyses were performed. The covariables included baseline demographic characteristics, comorbidity disease, neoadjuvant chemotherapy, tumor location, laboratory parameters, intraoperative related variables. RESULTS In all patients, the incidence of postoperative pneumonia in esophagectomy was 32.77% (36.90% in DLT group and 26.38% in SLT group). After adjusting for potential risk factors, we found that using an SLT in esophagectomy was associated with lower risk of postoperative pneumonia compared to using a DLT (Odd ratio = 0.41, 95% confidence interval (CI): 0.22, 0.77, p = 0.0057). Besides DLT, smoking history, combined intravenous and inhalation anesthesia (CIIA) and vasoactive drug use were all significant and independent risk factors for postoperative pneumonia in esophagectomy. These results remained stable and reliable after subgroup analysis. CONCLUSIONS During esophagectomy, there is significant association between the type of ETT (DLT or SLT) and PP. Patients who were intubated with a single lumen tube may have a lower rate of postoperative pneumonia than those who were intubated with a double lumen tube. This finding requires verification in follow-up studies.
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Affiliation(s)
- Xukeng Guo
- Department of Anesthesiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou City, Guangdong Province, China
| | - Weiqi Ke
- Department of Anesthesiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou City, Guangdong Province, China
| | - Xin Yang
- Department of Anesthesiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou City, Guangdong Province, China
| | - Xinying Zhao
- Department of Anesthesiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou City, Guangdong Province, China
| | - Meizhen Li
- Department of Anesthesiology, the First Affiliated Hospital of Shantou University Medical College, No. 57 Changping Road, Jinping District, Shantou City, Guangdong Province, China.
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Okamoto K, Inaki N, Saito H, Shimada M, Yamaguchi T, Tsuji T, Moriyama H, Kinoshita J, Makino I, Nakamura K, Takamura H, Ninomiya I. Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study. BMC Surg 2023; 23:242. [PMID: 37596560 PMCID: PMC10439606 DOI: 10.1186/s12893-023-02131-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/29/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND The degree of difficulty in the overall procedure and forceps handling encountered by surgeons is greatly influenced by the positional relationship of intrathoracic organs in minimally invasive esophagectomy. This study aimed to identify the anatomical factors associated with the difficulty of minimally invasive esophagectomy assessed by intraoperative injuries and postoperative outcomes. METHODS Minimally invasive esophagectomy in the left-decubitus position was performed in 258 patients. We defined α (mm) as the anteroposterior distance between the front of the vertebral body and aorta, β (mm) as the distance between the center of the vertebral body and center of the aorta, and γ (degree) as the angle formed at surgeon's right-hand port site by insertion of lines from the front of aorta and from the front of vertebrae in the computed tomography slice at the operator's right-hand forceps hole level. We retrospectively analyzed the correlations among clinico-anatomical factors, surgeon- or assistant-caused intraoperative organ injuries, and postoperative complications. RESULTS Intraoperative injuries significantly correlated with shorter α (0.2 vs. 3.9), longer β (33.0 vs. 30.5), smaller γ (3.0 vs. 4.3), R1 resection (18.5% vs. 8.3%), and the presence of intrathoracic adhesion (46% vs. 26%) compared with the non-injured group. Division of the median values into two groups showed that shorter α and smaller γ were significantly associated with organ injury. Longer β was significantly associated with postoperative tachycardia onset, respiratory complications, and mediastinal recurrence. Furthermore, the occurrence of intraoperative injuries was significantly associated with the onset of postoperative pulmonary complications. CONCLUSIONS Intrathoracic anatomical features greatly affected the procedural difficulty of minimally invasive esophagectomy, suggesting that preoperative computed tomography simulation and appropriate port settings may improve surgical outcomes.
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Affiliation(s)
- Koichi Okamoto
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan.
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku, 920-0293, Ishikawa, Japan.
| | - Noriyuki Inaki
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Hiroto Saito
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Mari Shimada
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Takahisa Yamaguchi
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, 920-8530, Ishikawa, Japan
| | - Toshikatsu Tsuji
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Hideki Moriyama
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Jun Kinoshita
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Isamu Makino
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medical Science, Kanazawa University, 13- 1 Takara-machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Keishi Nakamura
- Department of Gastrointestinal Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara- machi, Kanazawa, 920-8641, Ishikawa, Japan
| | - Hiroyuki Takamura
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku, 920-0293, Ishikawa, Japan
| | - Itasu Ninomiya
- Department of Surgery, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui, 910-0846, Japan
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Grantham JP, Hii A, Shenfine J. Combined and intraoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:1485-1500. [PMID: 37555117 PMCID: PMC10405120 DOI: 10.4240/wjgs.v15.i7.1485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions. AIM To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes. METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness. RESULTS Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness. CONCLUSION Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- Department of General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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Grantham JP, Hii A, Shenfine J. Preoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:450-470. [PMID: 37032794 PMCID: PMC10080602 DOI: 10.4240/wjgs.v15.i3.450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 02/23/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making.
AIM To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.
METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness.
RESULTS The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness.
CONCLUSION Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Adelaide 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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Lang K, Wang X, Wei T, Gu Z, Song Y, Yang D, Wang H. Concomitant preoperative airflow obstruction confers worse prognosis after trans-thoracic surgery for esophageal cancer. Front Surg 2023; 9:966340. [PMID: 36726951 PMCID: PMC9885207 DOI: 10.3389/fsurg.2022.966340] [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: 06/10/2022] [Accepted: 10/28/2022] [Indexed: 01/17/2023] Open
Abstract
Background Airflow obstruction is a critical element of chronic airway diseases. This study aimed to evaluate the impact of preoperative airflow obstruction on the prognosis of patients following surgery for esophageal carcinoma. Methods A total of 821 esophageal cancer patients were included and classified into two groups based on whether or not they had preoperative airflow obstruction. Airflow obstruction was defined as a forced expiration volume in the first second (FEV1)/forced vital capacity (FVC) ratio below the lower limit of normal (LLN). A retrospective analysis of the impact of airflow obstruction on the survival of patients with esophageal carcinoma undergoing esophagectomy was performed. Results Patients with airflow obstruction (102/821, 12.4%) had lower three-year overall (42/102, 58.8%) and progression-free survival rate (47/102, 53.9%) than those without airflow obstruction (P < 0.001). Multivariate analyses showed that airflow obstruction was an independent risk factor for overall survival (Hazard Ratio = 1.66; 95% CI: 1.17-2.35, P = 0.004) and disease progression (Hazard Ratio = 1.51; 95% CI: 1.1-2.08; P = 0.01). A subgroup analysis revealed that the above results were more significant in male patients, BMI < 23 kg/m2 patients or late-stage cancer (stage III-IVA) (P = 0.001) patients and those undergoing open esophagectomy (P < 0.001). Conclusion Preoperative airflow obstruction defined by FEV1/FVC ratio below LLN was an independent risk factor for mortality in esophageal cancer patients after trans-thoracic esophagectomy. Comprehensive management of airflow obstruction and more personalized surgical decision-making are necessary to improve survival outcomes in esophageal cancer patients.
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Affiliation(s)
- Ke Lang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaocen Wang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tingting Wei
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaolin Gu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yansha Song
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dong Yang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,Shanghai Key Laboratory of Lung Inflammation and Injury, Shanghai, China,Correspondence: Hao Wang Dong Yang
| | - Hao Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China,Correspondence: Hao Wang Dong Yang
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12
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Kamada T, Ohdaira H, Ito E, Takahashi J, Nakashima K, Nakaseko Y, Suzuki N, Yoshida M, Eto K, Suzuki Y. Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer. Sci Rep 2022; 12:16374. [PMID: 36180776 PMCID: PMC9525668 DOI: 10.1038/s41598-022-20967-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.
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Affiliation(s)
- Teppei Kamada
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan.
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Junji Takahashi
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Keigo Nakashima
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Yuichi Nakaseko
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Norihiko Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
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Reichert M, Lang M, Pons-Kühnemann J, Sander M, Padberg W, Hecker A. Perioperative statin medication impairs pulmonary outcome after abdomino-thoracic esophagectomy. Perioper Med (Lond) 2022; 11:47. [PMID: 36104793 PMCID: PMC9472330 DOI: 10.1186/s13741-022-00280-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although surgery is the curative option of choice for patients with locally advanced esophageal cancer, morbidity, especially the rate of pulmonary complications, and consequently mortality of patients undergoing abdomino-thoracic esophagectomy remain unacceptably high. Causes for developing post-esophagectomy pulmonary complications are trauma to the lung and thoracic cavity as well as systemic inflammatory response. Statins are known to influence inflammatory pathways, but whether perioperative statin medication impacts on inflammatory response and pulmonary complication development after esophagectomy had not been investigated, yet. Methods Retrospective analysis and propensity score matching of patients, who either received perioperative statin medication [statin( +)] or not [statin( −)], with regard to respiratory impairment (PaO2/FiO2 < 300 mmHg), pneumonia development, and inflammatory serum markers after abdomino-thoracic esophagectomy. Results Seventy-eight patients who underwent abdomino-thoracic esophagectomy for cancer were included into propensity score pair-matched analysis [statin( +): n = 26 and statin( −): n = 52]. Although no differences were seen in postoperative inflammatory serum markers, C-reactive protein values correlated significantly with the development of pneumonia beyond postoperative day 3 in statin( −) patients. This effect was attenuated under statin medication. No difference was seen in cumulative incidences of respiratory impairment; however, significantly higher rate (65.4% versus 38.5%, p = 0.0317, OR 3.022, 95% CI 1.165–7.892) and higher cumulative incidence (p = 0.0468) of postoperative pneumonia were seen in statin( +) patients, resulting in slightly longer postoperative stay on intensive care unit (p = 0.0612) as well as significantly prolonged postoperative in-hospital stay (p = 0.0185). Conclusions Development of pulmonary complications after abdomino-thoracic esophagectomy is multifactorial but frequent. The establishment of preventive measures into the perioperative clinical routine is mandatory for an improved patient outcome. Perioperative medication with statins might influence pneumonia development in the highly vulnerable lung after abdomino-thoracic esophagectomy. Perioperative interruption of statin medication might be beneficial in appropriate patients; however, further clinical trials and translational studies are needed to prove this hypothesis.
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14
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Lee S, Suh YS, Kang SH, Won Y, Park YS, Ahn SH, Kim HH. Should total omentectomy be performed for advanced gastric cancer?: The role of omentectomy during laparoscopic gastrectomy for advanced gastric cancer. Surg Endosc 2022; 36:6937-6948. [PMID: 35141774 DOI: 10.1007/s00464-022-09039-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/03/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the era of minimally invasive surgery, laparoscopic partial omentectomy (LPO) has seen widespread use as a curative surgical procedure for early gastric cancer. However, scientific evidence of the extent of omentectomy during laparoscopic gastrectomy remains unclear for advanced gastric cancer (AGC). METHODS We analyzed 666 eligible patients who underwent laparoscopic gastrectomy for AGC with curative intent between 2014 and 2018. Surgical outcome and postoperative prognosis were compared between LPO and laparoscopic total omentectomy (LTO) groups after 2:1 propensity score matching with age, sex, body mass index, tumor size, pT stage, pN stage, gastrectomy type, and clinical T stage as covariates. RESULTS After extensive matching, there was no significant difference in pathologic or clinical stages between the LPO (n = 254) and LTO (n = 177) groups. LPO provided a significantly shorter operation time than LTO (199.2 ± 64.8 vs. 248.1 ± 68.3 min, P < 0.001). Pulmonary complication within postoperative 30 days was significantly lower in the LPO group (4.4 vs. 10.3%, P = 0.018). In multivariate analysis, LTO was the independent risk factor for pulmonary complication (odds ratio [OR] 2.53, 95% confidence interval [95% CI] 1.12-5.73, P = 0.025), which became more obvious in patients with a Charlson's comorbidity index of 4 or higher (OR 27.43, 95% CI 1.35-558.34, P = 0.031). The 5-year overall survival rate (OS) and 3-year recurrence-free survival (RFS) rates were not significantly different between the two groups, even after stage stratification. CONCLUSION LPO provided significantly shorter operation time and less pulmonary complication than LTO without compromising 5-year OS and 3-year RFS for AGC. LTO was the independent risk factor for pulmonary complications, which became more evident in patients with severe comorbidities.
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Affiliation(s)
- Sangjun Lee
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
| | - So Hyun Kang
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Yongjoon Won
- Department of Surgery, Seongnam Citizens Medical Center, Seongnam-si, South Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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15
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Lin SH, Liao K, Lei X, Verma V, Shaaban S, Lee P, Chen AB, Koong AC, Hoftstetter WL, Frank SJ, Liao Z, Shih YCT, Giordano SH, Smith GL. Health Care Resource Utilization for Esophageal Cancer Using Proton versus Photon Radiation Therapy. Int J Part Ther 2022; 9:18-27. [PMID: 35774487 PMCID: PMC9238132 DOI: 10.14338/ijpt-22-00001.1] [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: 01/03/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose In patients treated with chemoradiation for esophageal cancer (EC), randomized trial data demonstrate that proton beam therapy (PBT) reduces toxicities and postoperative complications (POCs) compared with intensity-modulated radiation therapy (IMRT). However, whether radiation therapy modality affects postoperative health care resource utilization remains unknown. Materials and Methods We examined 287 patients with EC who received chemoradiation (prescribed 50.4 Gy/GyE) followed by esophagectomy, including a real-world observational cohort of 237 consecutive patients treated from 2007 to 2013 with PBT (n = 81) versus IMRT (n = 156); and an independent, contemporary comparison cohort of 50 patients from a randomized trial treated from 2012 to 2019 with PBT (n = 21) versus IMRT (n = 29). Postoperative complications were abstracted from medical records. Health care charges were obtained from institutional claims and adjusted for inflation (2021 dollars). Charge differences (Δ = $PBT - $IMRT) were compared by treatment using adjusted generalized linear models with the gamma distribution. Results Baseline PBT versus IMRT characteristics were not significantly different. In the observational cohort, during the neoadjuvant chemoradiation phase, health care charges were higher for PBT versus IMRT (Δ = +$71,959; 95% confidence interval [CI], $62,274-$82,138; P < .001). There was no difference in surgical charges (Δ = -$2234; 95% CI, -$6003 to $1695; P = .26). However, during postoperative hospitalization following esophagectomy, health care charges were lower for PBT versus IMRT (Δ = -$25,115; 95% CI, -$37,625 to -$9776; P = .003). In the comparison cohort, findings were analogous: Charges were higher for PBT versus IMRT during chemoradiation (Δ = +$61,818; 95% CI, $49,435-$75,069; P < .001), not different for surgery (Δ = -$4784; 95% CI, -$6439 to $3487; P = .25), and lower for PBT postoperatively (Δ = -$27,048; 95% CI, -$41,974 to -$5300; P = .02). Lower postoperative charges for PBT were especially seen among patients with any POCs in the contemporary comparison (Δ = -$176,448; 95% CI, -$209,782 to -$78,813; P = .02). Conclusion Higher up-front chemoradiation resource utilization for PBT in patients with EC was partially offset postoperatively, moderated by reduction in POC risks. Results extend existing clinical evidence of toxicity reduction with PBT.
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Affiliation(s)
- Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaiping Liao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherif Shaaban
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aileen B Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L Hoftstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Yoshida N, Horinouchi T, Eto K, Harada K, Sawayama H, Imamura Y, Iwatsuki M, Ishimoto T, Baba Y, Miyamoto Y, Watanabe M, Baba H. Prognostic Value of Pretreatment Red Blood Cell Distribution Width in Patients With Esophageal Cancer Who Underwent Esophagectomy: A Retrospective Study. ANNALS OF SURGERY OPEN 2022; 3:e153. [PMID: 37601607 PMCID: PMC10431288 DOI: 10.1097/as9.0000000000000153] [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: 09/08/2021] [Accepted: 03/03/2022] [Indexed: 11/27/2022] Open
Abstract
Objective This comprehensive analysis aimed to elucidate the mechanism underlying how high pretreatment red blood cell distribution width (RDW) reflects poor prognosis after esophagectomy for esophageal cancer. Background Several cohort studies have reported that preoperative RDW might be a predictive marker for poor prognosis after esophagectomy; however, the underlying mechanism of this relationship has not been elucidated. Methods This study included 626 patients with esophageal cancer who underwent esophagectomy between April 2005 and November 2020. A retrospective investigation of the association between pretreatment RDW and clinicopathological features, blood data, short-term outcomes, and prognosis was conducted using a prospectively entered institutional clinical database and the latest follow-up data. Results Of 626 patients, 87 (13.9%) had a high pretreatment RDW. High RDW was significantly associated with several disadvantageous characteristics regarding performance status, the American Society of Anesthesiologists physical status, respiratory comorbidity, and nutritional status. Similarly, high RDW correlated with frequent postoperative morbidities (respiratory morbidity and reoperation; P = 0.022 and 0.034, respectively), decreased opportunities for adjuvant chemotherapy (P = 0.0062), and increased death from causes other than esophageal cancer (P = 0.046). Finally, RDW could be an independent predictor of survival after esophagectomy (hazard ratio, 1.47; 95% confidence interval, 1.009-2.148; P = 0.045). Conclusion High pretreatment RDW reflected various adverse backgrounds and it could be a surrogate marker of poor prognosis in patients who have undergone esophagectomy for esophageal cancer.
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Affiliation(s)
- Naoya Yoshida
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Division of Translational Research and Advanced Treatment against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Tomo Horinouchi
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuto Harada
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Sawayama
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masaaki Iwatsuki
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Division of Translational Research and Advanced Treatment against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hideo Baba
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Yoshida N, Sasaki K, Kanetaka K, Kimura Y, Shibata T, Ikenoue M, Nakashima Y, Sadanaga N, Eto K, Tsuruda Y, Kobayashi S, Nakanoko T, Suzuki K, Takeno S, Yamamoto M, Morita M, Toh Y, Baba H. High Pretreatment Mean Corpuscular Volume Can Predict Worse Prognosis in Patients With Esophageal Squamous Cell Carcinoma who Have Undergone Curative Esophagectomy: A Retrospective Multicenter Cohort Study. ANNALS OF SURGERY OPEN 2022; 3:e165. [PMID: 37601605 PMCID: PMC10431247 DOI: 10.1097/as9.0000000000000165] [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: 12/09/2021] [Accepted: 04/12/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To establish the prognostic value of mean corpuscular volume (MCV) in patients with esophageal squamous cell carcinoma (ESCC) who have undergone esophagectomy. BACKGROUND The MCV increases in patients with high alcohol and tobacco consumption. Such a lifestyle can be a risk factor for malnutrition, comorbidities related to those habits, and multiple primary malignancies, which may be associated with frequent postoperative morbidity and poor prognosis. METHODS This study included 1673 patients with ESCC who underwent curative esophagectomy at eight institutes between April 2005 and November 2020. Patients were divided into normal and high MCV groups according to the standard value of their pretreatment MCV. Clinical background, short-term outcomes, and prognosis were retrospectively compared between the groups. RESULTS Overall, 26.9% of patients had a high MCV, which was significantly associated with male sex, habitual smoking and drinking, multiple primary malignancies, and malnutrition, as estimated by the body mass index, hemoglobin and serum albumin values, and the Geriatric Nutritional Risk Index. Postoperative respiratory morbidity (P = 0.0075) frequently occurred in the high MCV group. A high MCV was an independent prognostic factor for worse overall survival (hazard ratio, 1.27; 95% confidence interval, 1.049-1.533; P = 0.014) and relapse-free survival (hazard ratio, 1.23; 95% confidence interval, 1.047-1.455; P = 0.012). CONCLUSIONS A high MCV correlates with habitual drinking and smoking, malnutrition, and multiple primary malignancies and could be a surrogate marker of worse short-term and long-term outcomes in patients with ESCC who undergo esophagectomy.
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Affiliation(s)
- Naoya Yoshida
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Chuoku, Kumamoto, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima-shi, Kagoshima, Japan
| | - Kengo Kanetaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasue Kimura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Tomotaka Shibata
- Department of Gastroenterological and Pediatric Surgery, Oita University, Hasama, Oita, Japan
| | - Makoto Ikenoue
- Division of Gastrointestinal-Endocrine-Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, Japan
| | - Yuichiro Nakashima
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, Miniami-ku, Fukuoka, Japan
| | - Noriaki Sadanaga
- Department of Surgery, Saiseikai Fukuoka General Hospital, Chuo-ku, Fukuoka, Japan
| | - Kojiro Eto
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Chuoku, Kumamoto, Japan
| | - Yusuke Tsuruda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima-shi, Kagoshima, Japan
| | - Shinichiro Kobayashi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomonori Nakanoko
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Kosuke Suzuki
- Department of Gastroenterological and Pediatric Surgery, Oita University, Hasama, Oita, Japan
| | - Shinsuke Takeno
- Division of Gastrointestinal-Endocrine-Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, Japan
| | - Manabu Yamamoto
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, Miniami-ku, Fukuoka, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, Miniami-ku, Fukuoka, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, Miniami-ku, Fukuoka, Japan
| | - Hideo Baba
- From the Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Chuoku, Kumamoto, Japan
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18
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Ishikawa S, Ozato S, Ebina T, Yoshioka S, Miichi M, Watanabe M, Yokota M. Early postoperative pulmonary complications after minimally invasive esophagectomy in the prone position: incidence and perioperative risk factors from the perspective of anesthetic management. Gan To Kagaku Ryoho 2022; 70:659-667. [DOI: 10.1007/s11748-022-01818-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/01/2022] [Indexed: 12/17/2022]
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Prophylactic Penehyclidine Inhalation for Prevention of Postoperative Pulmonary Complications in High-risk Patients: A Double-blind Randomized Trial. Anesthesiology 2022; 136:551-566. [PMID: 35226725 DOI: 10.1097/aln.0000000000004159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative pulmonary complications are common. Aging and respiratory disease provoke airway hyperresponsiveness, high-risk surgery induces diaphragmatic dysfunction, and general anesthesia contributes to atelectasis and peripheral airway injury. This study therefore tested the hypothesis that inhalation of penehyclidine, a long-acting muscarinic antagonist, reduces the incidence of pulmonary complications in high-risk patients over the initial 30 postoperative days. METHODS This single-center double-blind trial enrolled 864 patients age over 50 yr who were scheduled for major upper-abdominal or noncardiac thoracic surgery lasting 2 h or more and who had an Assess Respiratory Risk in Surgical Patients in Catalonia score of 45 or higher. The patients were randomly assigned to placebo or prophylactic penehyclidine inhalation from the night before surgery through postoperative day 2 at 12-h intervals. The primary outcome was the incidence of a composite of pulmonary complications within 30 postoperative days, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis. RESULTS A total of 826 patients (mean age, 64 yr; 63% male) were included in the intention-to-treat analysis. A composite of pulmonary complications was less common in patients assigned to penehyclidine (18.9% [79 of 417]) than those receiving the placebo (26.4% [108 of 409]; relative risk, 0.72; 95% CI, 0.56 to 0.93; P = 0.010; number needed to treat, 13). Bronchospasm was less common in penehyclidine than placebo patients: 1.4% (6 of 417) versus 4.4% (18 of 409; relative risk, 0.327; 95% CI, 0.131 to 0.82; P = 0.011). None of the other individual pulmonary complications differed significantly. Peak airway pressures greater than 40 cm H2O were also less common in patients given penehyclidine: 1.9% (8 of 432) versus 4.9% (21 of 432; relative risk, 0.381; 95% CI, 0.171 to 0.85; P = 0.014). The incidence of other adverse events, including dry mouth and delirium, that were potentially related to penehyclidine inhalation did not differ between the groups. CONCLUSIONS In high-risk patients having major upper-abdominal or noncardiac thoracic surgery, prophylactic penehyclidine inhalation reduced the incidence of pulmonary complications without provoking complications. EDITOR’S PERSPECTIVE
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20
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Tong C, Liu Y, Wu J. Development and validation of a novel nomogram for postoperative pulmonary complications following minimally invasive esophageal cancer surgery. Updates Surg 2021; 74:1375-1382. [PMID: 34689289 DOI: 10.1007/s13304-021-01196-z] [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: 08/23/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022]
Abstract
Postoperative pulmonary complications (PPCs) are the most common complications following minimally invasive esophagectomy (MIE) and can be associated with adverse outcomes. This study aims to construct a nomogram based on clinical factors to predict PPCs and investigate related early outcomes. Clinical data of 969 consecutive patients receiving MIE were retrospectively collected. Univariate and multivariate analysis were performed to select independent predictors. Using independent predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal verification. Early outcomes of PPCs were analyzed. The incidence of PPCs following MIE was 39.6% (384 out of 969). In multivariate analysis, older age (Odds ratio (OR) 1.034, P < 0.001), higher body mass index (OR 0.993, P = 0.003), heavy smoking (OR 1.396, P = 0.027), FEV1/FVC < 105% (OR 1.958, P < 0.001), chemoradiotherapy (OR 0.653, P = 0.039), estimated blood loss ≥ 400 mL (OR 2.582, P = 0.018), general anesthesia (vs Combined thoracic paravertebral blockade, OR 1.578, P = 0.014), operative time ≥ 240 min (OR 1.388, P = 0.027), squamous cell carcinoma (OR 2.099, P = 0.036) and conversion to thoracotomy (OR 2.820, P = 0.026) were independent predictors for PPCs. These ten independent predictors were used to develop a nomogram, with concordance index (C index) value of 0.662 and good calibration. After internal validation, similarly good calibration and discrimination (C index, 0.654; 95% CI 0.614-0.690) were observed. Patients developing PPCs had higher rates of anastomotic leakage, reoperation, ICU and 30-day readmissions, and prolonged ICU and hospital stays (P < 0.05). Our study identified ten predictors for PPCs, which were associated with poor early outcomes. The proposed nomogram can be a useful tool to identify patients at high risk of PPCs after MIE.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.,Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Liu
- Statistical Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.
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21
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Janssen HJB, Gantxegi A, Fransen LFC, Nieuwenhuijzen GAP, Luyer MDP. Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy. Nutrients 2021; 13:3616. [PMID: 34684617 PMCID: PMC8539606 DOI: 10.3390/nu13103616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5-8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0-4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2-6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8-15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0-16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.
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Affiliation(s)
- Henricus J. B. Janssen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602ZA Eindhoven, The Netherlands; (H.J.B.J.); (L.F.C.F.); (G.A.P.N.)
| | - Amaia Gantxegi
- Department of Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Laura F. C. Fransen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602ZA Eindhoven, The Netherlands; (H.J.B.J.); (L.F.C.F.); (G.A.P.N.)
| | - Grard A. P. Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602ZA Eindhoven, The Netherlands; (H.J.B.J.); (L.F.C.F.); (G.A.P.N.)
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602ZA Eindhoven, The Netherlands; (H.J.B.J.); (L.F.C.F.); (G.A.P.N.)
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22
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Higuchi T, Ozawa S, Koyanagi K, Ninomiya Y, Yatabe K, Yamamoto M, Tajima K, Nomura T, Niwa T. Usefulness of prone-position computed tomography as preoperative simulation prior to thoracoscopic esophagectomy for thoracic esophageal cancer. Esophagus 2021; 18:764-772. [PMID: 33999306 DOI: 10.1007/s10388-021-00852-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/10/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The study aimed to evaluate the usefulness of prone-position computed tomography (CT) for predicting relevant thoracic procedure outcomes in minimally invasive esophagectomy (MIE) for thoracic esophageal cancer. MATERIALS AND METHODS A total of 59 patients underwent esophagectomy between May 2019 and December 2020 in Tokai University Hospital. Preoperative CT imaging was conducted with the patient in both the supine and prone positions, and the magnitude of change in the intramediastinal space was calculated. In the 56 patients (94.9%) who had undergone MIE, the effects of such a difference on the surgical outcomes were analyzed. RESULTS A significant correlation of the magnitude of change in VE (distance between ventral aspect of the vertebral body and the midpoint of the esophagus) with the surgical outcome was revealed in the 17 patients (30.4%) in whom the magnitude of change in VE was over the 75th percentile. That is, in this subgroup, the magnitude of change in VE showed a negative correlation with the thoracic operation time (rs = - 0.57, p = 0.01) and blood loss during the thoracic procedure (rs = - 0.46, p = 0.01). Multivariate analysis identified a magnitude of change in VE ≥ 9 mm (OR = 0.14, p = 0.03) as an independent risk factor for postoperative pneumonia. CONCLUSIONS This study indicates that preoperative prone-position CT imaging is useful for predicting the level of ease or difficulty of securing an adequate operative field, surgical outcomes, and the risk of postoperative pneumonia in MIE.
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Affiliation(s)
- Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Takakiyo Nomura
- Department of Radiology, Tokai University School of Medicine, Isehara, Japan
| | - Tetsu Niwa
- Department of Radiology, Tokai University School of Medicine, Isehara, Japan
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23
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Yoshida N, Harada K, Iwatsuki M, Baba Y, Baba H. Precautions for avoiding pulmonary morbidity after esophagectomy. Ann Gastroenterol Surg 2020; 4:480-484. [PMID: 33005841 PMCID: PMC7511556 DOI: 10.1002/ags3.12354] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/27/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022] Open
Abstract
Pulmonary morbidity is the most common complication after esophagectomy. Importantly, it is the main cause of surgery-related mortality and possibly adversely affects the long-term outcome after surgery in patients with esophageal cancer. There is considerable accumulated evidence on multidisciplinary approaches to reduce post-operative pulmonary morbidity. A comprehensive review of the precautionary measures that have so far been shown to be effective in previous literature is of utmost importance. We herein update and summarize the perioperative and surgical approaches to diminish pulmonary morbidity. Pre-operative smoking cessation, respiratory rehabilitation, maintaining oral hygiene, perioperative nutritional intervention, enforcement of less invasive surgery, perioperative administration of steroid, and total management by a multidisciplinary team could be the key factors contributing to reduction in pulmonary morbidity.
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Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological SurgeryGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Kazuto Harada
- Department of Gastroenterological SurgeryGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Masaaki Iwatsuki
- Department of Gastroenterological SurgeryGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Yoshifumi Baba
- Department of Gastroenterological SurgeryGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
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24
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Risk Factors for Postoperative Pneumonia After Esophagectomy for Esophageal Cancer. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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25
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Ahmadinejad M, Soltanian A, Maghsoudi LH. Risk factors and therapeutic measures for postoperative complications associated with esophagectomy. Ann Med Surg (Lond) 2020; 55:167-173. [PMID: 32489659 PMCID: PMC7262474 DOI: 10.1016/j.amsu.2020.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023] Open
Abstract
Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ali Soltanian
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Leila Haji Maghsoudi
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach. J Clin Med 2020; 9:jcm9061896. [PMID: 32560416 PMCID: PMC7355913 DOI: 10.3390/jcm9061896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/23/2022] Open
Abstract
Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO2/FiO2 ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman's rank correlation coefficient (rsp) = -0.267, p = 0.006), especially of laparotomy (rsp = -0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1-25) and 8.5 (3-14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.
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27
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Patel K, Askari A, Moorthy K. Long-term oncological outcomes following completely minimally invasive esophagectomy versus open esophagectomy. Dis Esophagus 2020; 33:5707339. [PMID: 31950180 DOI: 10.1093/dote/doz113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/09/2019] [Accepted: 01/02/2020] [Indexed: 12/11/2022]
Abstract
Open esophagectomy (OE) for esophageal and gastroesophageal junctional cancers is associated with high morbidity. Completely minimally invasive esophagectomy (CMIE) techniques have evolved over the last two decades and significantly reduce surgical trauma compared to open surgery. Despite this, long-term oncological outcomes following CMIE compared to OE remain unclear. This systematic review and meta-analysis aimed to compare overall 5-year survival (OFS) and disease-free 5-year survival (DFFS) between CMIE and OE. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials was conducted. The PROSPERO database was also searched for studies comparing OFS and DFFS between CMIE and OE. The Newcastle Ottawa Scale was used to assess study quality for included studies. Overall, seven studies (containing 949 patients: 527 OE and 422 CMIE) were identified from screening. On pooled meta-analysis, there was no significant difference in OFS or DFFS between CMIE and OE cohorts ([odds ratio 1.12; 95% CI: 0.85 to 1.48; P = 0.41] and [odds ratio 1.34; 95% CI: 0.81-2.22; P = 0.25] respectively). Sensitivity and subgroup analysis with high-quality studies, three highest sample sized studies, and three most recent studies also revealed no difference in long-term oncological outcomes between the two operative groups. This review demonstrates long-term oncological outcomes following CMIE appear equivalent to OE based on amalgamation of existing published literature. Limited high-level evidence comparing OFS and DFFS between CMIE and OE exists. Further research with a randomized controlled trial is required to clinically validate these findings.
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Affiliation(s)
- K Patel
- Department of Surgery and Cancer, Imperial College, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Moorthy
- Department of Surgery and Cancer, Imperial College, London, UK
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28
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Response to Comment on "Can Minimally Invasive Esophagectomy Replace Open Esophagectomy for Esophageal Cancer? Latest Analysis of 24,233 Esophagectomies From the Japanese National Clinical Database". Ann Surg 2020; 270:e110-e111. [PMID: 31726636 DOI: 10.1097/sla.0000000000003337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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29
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Saunders JH, Yanni F, Dorrington MS, Bowman CR, Vohra RS, Parsons SL. Impact of postoperative complications on disease recurrence and long-term survival following oesophagogastric cancer resection. Br J Surg 2019; 107:103-112. [DOI: 10.1002/bjs.11318] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/02/2019] [Accepted: 07/01/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Postoperative complications after resection of oesophagogastric carcinoma can result in considerable early morbidity and mortality. However, the long-term effects on survival are less clear.
Methods
All patients undergoing intentionally curative resection for oesophageal or gastric cancer between 2006 and 2016 were selected from an institutional database. Patients were categorized by complication severity according to the Clavien–Dindo classification (grades 0–V). Complications were defined according to an international consensus statement. The effect of leak and severe non-leak-related complications on overall survival, recurrence and disease-free survival was assessed using Kaplan–Meier analyses to evaluate differences between groups. All factors significantly associated with survival in univariable analysis were entered into a Cox multivariable regression model with stepwise elimination.
Results
Some 1100 patients were included, with a median age of 69 (range 28–92) years; 48·1 per cent had stage III disease and cancer recurred in 428 patients (38·9 per cent). Complications of grade III or higher occurred in 244 patients (22·2 per cent). The most common complications were pulmonary (29·9 per cent), with a 13·0 per cent incidence of pneumonia. Rates of atrial dysrhythmia and anastomotic leak were 10·0 and 9·6 per cent respectively. Patients with a grade III–IV leak did not have significantly reduced overall survival compared with those who had grade 0–I complications. However, patients with grade III–IV non-leak-related complications had reduced median overall survival (19·7 versus 42·7 months; P < 0·001) and disease-free survival (18·4 versus 36·4 months; P < 0·001). Cox regression analysis identified age, tumour stage, resection margin and grade III–IV non-leak-related complications as independent predictors of poor overall and disease-free survival.
Conclusion
Beyond the acute postoperative period, anastomotic leak does not adversely affect survival, however, other severe postoperative complications do reduce long-term overall and disease-free survival.
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Affiliation(s)
- J H Saunders
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - F Yanni
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - M S Dorrington
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C R Bowman
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - R S Vohra
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - S L Parsons
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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Uchihara T, Yoshida N, Baba Y, Nakashima Y, Kimura Y, Saeki H, Takeno S, Sadanaga N, Ikebe M, Morita M, Toh Y, Nanashima A, Maehara Y, Baba H. Esophageal Position Affects Short-Term Outcomes After Minimally Invasive Esophagectomy: A Retrospective Multicenter Study. World J Surg 2019; 44:831-837. [PMID: 31701157 DOI: 10.1007/s00268-019-05273-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anatomical esophageal position may affect the short-term outcomes after minimally invasive esophagectomy (MIE). A previous single-institutional retrospective study suggested that the presence of a left-sided esophagus (LSE) made MIE more difficult and increased the incidence of postoperative complications. METHODS The current study was a multicenter retrospective study of 303 patients with esophageal cancer who underwent MIE at six esophageal cancer high-volume centers in Kyushu, Japan, between April 2011 and August 2016. The patients were divided into the LSE (66 patients) and non-LSE groups (237 patients) based on the esophageal position on computed tomography images obtained with the patients in the supine position. RESULTS Univariate analysis showed that patients with LSE were significantly older than those with non-LSE (69 ± 8 vs. 65 ± 9 years; P = 0.002), had a significantly greater incidence of cardiovascular comorbidity (65.2% vs. 47.7%; P = 0.013), and a significantly longer operating time (612 ± 112 vs. 579 ± 102 min; P = 0.025). Logistic regression analysis verified that LSE was an independent risk factor for the incidence of pneumonia (odds ratio 3.3, 95% confidence interval 1.254-8.695; P = 0.016). CONCLUSIONS The presence of a LSE can increase the procedural difficulty of MIE and the incidence of morbidity after MIE. Thus, careful attention must be paid to anatomical esophageal position before performing MIE.
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Affiliation(s)
- Tomoyuki Uchihara
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yuichiro Nakashima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasue Kimura
- Department of Surgery, Iizuka Hosipital, Yoshiomachi 3-83, Iizuka, Fukuoka, 820-8505, Japan
| | - Hiroshi Saeki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shinsuke Takeno
- Division of Gastrointestinal-Endocrine-Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kihara 5200, Kiyotake, Miyazaki, 889-1692, Japan
| | - Noriaki Sadanaga
- Department of Surgery, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan
| | - Masahiko Ikebe
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, 3-1-1 Notame, Miniami-ku, Fukuoka, 811-1395, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, 3-1-1 Notame, Miniami-ku, Fukuoka, 811-1395, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization, Kyushu Cancer Center, 3-1-1 Notame, Miniami-ku, Fukuoka, 811-1395, Japan
| | - Atsushi Nanashima
- Division of Gastrointestinal-Endocrine-Pediatric Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kihara 5200, Kiyotake, Miyazaki, 889-1692, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan.
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Oesophago‐Gastric Anastomosis Study Group on behalf of the West Midlands Research Collaborative, Bundred JR, Kamarajah SK, Siaw‐Acheampong K, Nepogodiev D, Jefferies B, Singh P, Evans R, Griffiths EA, Alderson D, Gossage J, McKay S, Mohamed I, van Hillegersberg R, Vohra R, Wanigsooriya K, Whitehouse T, Bagajevas A, Bekele A, Blanco‐Colino R, Da Roit A, El Kafsi‐Mawley J, Gjata A, Gockel I, Castro RG, Harustiak T, Hsu P, Isik A, Kechagias A, Kennedy A, Kidane B, Mahendran HA, Mejia L, Moreno JI, Negoi I, Santiago AJ, Sayyed R, Schneider P, Soares AS, Sousa M, Takeda FR, Vanstraten S, Wallner B, Wijnhoven B, Achiam M, Agustin T, Akbar A, Al‐Bahrani A, Al‐Khyatt W, Albertsmeier M, Alghunaim E, Alkhaffaf B, Allum W, Am F, Andreollo N, Arndt A, Babor R, Barbosa J, Bardini R, Beardsmore D, Beban G, Bernardes A, Berrisford R, Bianchi A, Bjelovic M, Boddy A, Bolca C, Bonavina L, Bryce G, Byrom R, Casaca R, Chan D, Charalabopoulos A, Cheong E, Ciotola F, Colak E, Collins C, Constantinoiu S, Costa R, Dahlke M, Darling G, Dawas K, de Manzoni G, Denewer A, Devadas M, Dexter S, Dikinis S, Dimitrios T, Dolan J, Duong C, Egberts J, Elgharably Y, Elhadi M, Elmahi S, Farias FA, Fekaj E, Fernández J, Forshaw M, Freire J, French D, et alOesophago‐Gastric Anastomosis Study Group on behalf of the West Midlands Research Collaborative, Bundred JR, Kamarajah SK, Siaw‐Acheampong K, Nepogodiev D, Jefferies B, Singh P, Evans R, Griffiths EA, Alderson D, Gossage J, McKay S, Mohamed I, van Hillegersberg R, Vohra R, Wanigsooriya K, Whitehouse T, Bagajevas A, Bekele A, Blanco‐Colino R, Da Roit A, El Kafsi‐Mawley J, Gjata A, Gockel I, Castro RG, Harustiak T, Hsu P, Isik A, Kechagias A, Kennedy A, Kidane B, Mahendran HA, Mejia L, Moreno JI, Negoi I, Santiago AJ, Sayyed R, Schneider P, Soares AS, Sousa M, Takeda FR, Vanstraten S, Wallner B, Wijnhoven B, Achiam M, Agustin T, Akbar A, Al‐Bahrani A, Al‐Khyatt W, Albertsmeier M, Alghunaim E, Alkhaffaf B, Allum W, Am F, Andreollo N, Arndt A, Babor R, Barbosa J, Bardini R, Beardsmore D, Beban G, Bernardes A, Berrisford R, Bianchi A, Bjelovic M, Boddy A, Bolca C, Bonavina L, Bryce G, Byrom R, Casaca R, Chan D, Charalabopoulos A, Cheong E, Ciotola F, Colak E, Collins C, Constantinoiu S, Costa R, Dahlke M, Darling G, Dawas K, de Manzoni G, Denewer A, Devadas M, Dexter S, Dikinis S, Dimitrios T, Dolan J, Duong C, Egberts J, Elgharably Y, Elhadi M, Elmahi S, Farias FA, Fekaj E, Fernández J, Forshaw M, Freire J, French D, Gacevski G, Gaedcke J, Gananadha S, Gijon MM, Gokhale J, Gordon A, Grimminger P, Guevara R, Guner A, Gutknecht S, Mahmoodzadeh H, Halldestam I, Hedberg J, Heisterkamp J, Higgs S, Hii M, Hindmarsh A, Hoppner J, Isaza A, Izbicki J, Jacobs R, Jain P, Johansson J, Johnston B, Kafsi J, Kassa S, Kelty C, Khan I, Khoo D, Khyatt S, Kjaer D, Korkolis D, Kreuser N, Larsen M, Lau P, Leite J, Lewis W, Liakakos T, Loureiro C, Mahendran A, Maynard N, Mcgregor R, Mcnally S, Medina‐Franco H, Meguid R, Melhado R, Mercer S, Migliore M, Mingol F, Mogoanta S, Mohri Y, Mönig S, Moreno J, Motas N, Murphy T, Naqi S, Ni R, Niazi S, Oglesby S, Okonta K, Ortiz SR, Pal K, Palazzo F, Pascher A, Pascual M, Pata G, Pera M, Puig S, Ramirez J, Raptis D, Räsänen J, Reim D, Reynolds J, Robb W, Robertson K, Rosero G, Rosman C, Rossaak J, Saarnio J, Santiago A, Schiesser M, Scurtu R, Sekhniaidze D, Sevinç B, Skipworth R, So J, Trugeda MS, Syed A, Takahashi AML, Takeda F, Talbot M, Tareen M, Terashima M, Testini M, Tewari N, Tez M, Thomas M, Tirnaksiz M, Tonini V, Tu C, Turner P, Underwood T, Uzair A, Vallve‐Bernal M, Valmasoni M, Vicente C, Videira JF, Viswanath YKS, Weindelmayer J, White R, Wigle D, Wilkerson P, Wills V, Zacharakis E, Zuluaga M. International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA). World J Surg 2019; 43:2874-2884. [PMID: 31332491 DOI: 10.1007/s00268-019-05080-1] [Show More Authors] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy. METHOD The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit. RESULTS Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001). CONCLUSIONS This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.
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Worrall DM, Tanella A, DeMaria S, Miles BA. Anesthesia and Enhanced Recovery After Head and Neck Surgery. Otolaryngol Clin North Am 2019; 52:1095-1114. [PMID: 31551127 DOI: 10.1016/j.otc.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.
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Affiliation(s)
- Douglas M Worrall
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA
| | - Anthony Tanella
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Brett A Miles
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA.
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Gupta V, Bubis L, Kidane B, Mahar AL, Ringash J, Sutradhar R, Darling GE, Coburn NG. Readmission rates following esophageal cancer resection are similar at regionalized and non-regionalized centers: A population-based cohort study. J Thorac Cardiovasc Surg 2019; 158:934-942.e2. [DOI: 10.1016/j.jtcvs.2019.04.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
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Reichert M, Schistek M, Uhle F, Koch C, Bodner J, Hecker M, Hörbelt R, Grau V, Padberg W, Weigand MA, Hecker A. Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection. Sci Rep 2019; 9:11856. [PMID: 31413282 PMCID: PMC6694108 DOI: 10.1038/s41598-019-48234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.
| | - Magdalena Schistek
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Johannes Bodner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Department of Thoracic Surgery, München Klinik Bogenhausen, Englschalkinger Strasse 77, D-81925, Munich, Germany
| | - Matthias Hecker
- Department of Pulmonary and Critical Care Medicine, University of Giessen and Marburg Lung Center (UGMLC), University Hospital of Giessen, Klinikstrasse 33, D-35392, Giessen, Germany
| | - Rüdiger Hörbelt
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Veronika Grau
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Laboratory of Experimental Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University Giessen, Feulgenstrasse 10-12, D-35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
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Takesue Y, Miyata H, Gotoh M, Wakabayashi G, Konno H, Mori M, Kumamaru H, Ueda T, Nakajima K, Uchino M, Seto Y. Risk calculator for predicting postoperative pneumonia after gastroenterological surgery based on a national Japanese database. Ann Gastroenterol Surg 2019; 3:405-415. [PMID: 31346580 PMCID: PMC6635692 DOI: 10.1002/ags3.12248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/26/2019] [Accepted: 03/13/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The aim of the present study was to develop a risk calculator predictive of postoperative pneumonia in patients undergoing gastroenterological surgery. METHODS We analyzed data from 382 124 patients undergoing eight main gastroenterological surgeries between 2011 and 2013 using the National Clinical Database in Japan. A risk model was developed using multivariate logistic regression analysis with patient data from 2011 to 2012 (n = 247 604) and validated using data from 2013 (n = 134 520). RESULTS Pneumonia was observed in 11 105 patients (2.9%). After the input of significant primary disease and surgical procedures, 18 patient characteristics including gender, chronic obstructive pulmonary disease, sepsis, and need for any assistance in the activities of daily living, six laboratory parameters, and two intraoperative factors were used for risk calculation. Area under the receiver-operating characteristic curve was 0.822 (95% confidence interval, 0.817-0.826) in the derivation group and 0.826 (0.819-0.832) in the validation group. CONCLUSION The risk calculator accurately predicted the occurrence of pneumonia following gastroenterological surgery.
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Affiliation(s)
- Yoshio Takesue
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | | | - Mitsukazu Gotoh
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Go Wakabayashi
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | | | - Masaki Mori
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Hiraku Kumamaru
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Takashi Ueda
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | | | - Motoi Uchino
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
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Kanda M, Koike M, Tanaka C, Kobayashi D, Hayashi M, Yamada S, Omae K, Kodera Y. Risk Prediction of Postoperative Pneumonia After Subtotal Esophagectomy Based on Preoperative Serum Cholinesterase Concentrations. Ann Surg Oncol 2019; 26:3718-3726. [PMID: 31197518 DOI: 10.1245/s10434-019-07512-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients undergoing subtotal esophagectomy for esophageal cancer frequently experience postoperative pneumonia. Development of preoperatively determined predictors for postoperative pneumonia will facilitate identifying high-risk patients and will assist with informing patients about their risk of postoperative pneumonia, enabling physicians to estimate with greater accuracy, will result in tailoring perioperative management. METHODS Postoperative pneumonia was defined according to the revised Uniform Pneumonia Score. We analyzed the data for 355 patients to compare 32 potential predictive variables associated with postoperative pneumonia after subtotal esophagectomy. RESULTS Forty-one patients (11.5%) had postoperative pneumonia. Preoperative cholinesterase (ChE) concentrations demonstrated the greatest area under the curve value (0.662) to predict postoperative pneumonia (optimal cutoff value = 217 IU/l). Univariate analysis identified a continuous value of preoperative ChE concentration as a significant risk factor for postoperative pneumonia (P = 0.0014). Multivariable analysis using factors potentially relevant to pneumonia revealed that preoperative ChE concentration was one of independent risk factors for pneumonia after esophagectomy (P = 0.008). Patients with low ChE concentrations were at increased risk of postoperative pneumonia in most patient subgroups. Moreover, the odds ratios of low ChE concentrations were highest in patients undergoing neoadjuvant treatment. A combination of preoperative serum ChE concentrations and Brinkman index stratified patients into low, intermediate, and high risk of postoperative pneumonia. CONCLUSIONS Our findings indicate that preoperative ChE concentrations, particularly in combination with Brinkman index, may serve simply as a determined predictor of pneumonia after subtotal esophagectomy and may facilitate physicians' efforts to reduce the incidence of postoperative pneumonia.
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Affiliation(s)
- Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masahiko Koike
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Kobayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Omae
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yoshida N, Morito A, Nagai Y, Baba Y, Miyamoto Y, Iwagami S, Iwatsuki M, Hiyoshi Y, Eto K, Ishimoto T, Kiyozumi Y, Yagi T, Nomoto D, Akiyama T, Toihata T, Imamura Y, Watanabe M, Baba H. Clinical Importance of Sputum in the Respiratory Tract as a Predictive Marker of Postoperative Morbidity After Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2019; 26:2580-2586. [PMID: 31144141 DOI: 10.1245/s10434-019-07477-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Respiratory morbidity is common after esophagectomy and can be a major cause of surgery-related mortality. Thus, it is important to identify novel predictors that can preoperatively estimate the incidence of postoperative respiratory morbidity. Asymptomatic sputum in the respiratory tract is sometimes observed on preoperative computed tomography (CT). This study aimed to determine the clinical importance of sputum in the respiratory tract as a predictor of postoperative morbidity after esophagectomy for esophageal cancer. PATIENTS AND METHODS The study included 609 consecutive patients who underwent three-incisional esophagectomy for esophageal cancer between April 2005 and November 2018. RESULTS Among the patients, 76 (12.5%) had sputum in the respiratory tract on preoperative CT. This finding was significantly associated with older age, more extreme smoking habit, worse performance status, lower forced expiratory volume 1%, and more frequent pulmonary comorbidities. Additionally, the incidence of postoperative pneumonia was higher in these patients than in those without sputum (16 vs 8%, p = 0.028). Sputum in the main bronchus was associated with higher frequencies of morbidity of Clavien-Dindo classification (CDc) ≥ II (p = 0.019), severe morbidity of CDc ≥ IIIb (p = 0.058), pneumonia (p = 0.10), and pulmonary morbidity (p = 0.19) compared with the finding of sputum in the trachea alone. On multivariate analysis, sputum in the respiratory tract was an independent risk factor (hazard ratio, 2.07; 95% confidence interval, 1.019-4.207; p = 0.044) for postoperative pneumonia. CONCLUSIONS Sputum in the respiratory tract is a novel predictor of postesophagectomy pneumonia. Patients with sputum in the more distal respiratory tract might have high risk of postoperative morbidities.
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Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Atsushi Morito
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yohei Nagai
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Yuki Kiyozumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taisuke Yagi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daichi Nomoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takahiko Akiyama
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Otero J, Arnold MR, Kao AM, Schlosser KA, Prasad T, Lincourt AE, Heniford BT, Colavita PD. Short-term Outcomes of Esophagectomies in Octogenarians—An Analysis of ACS-NSQIP. J Surg Res 2019; 235:432-439. [DOI: 10.1016/j.jss.2018.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/01/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
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Impact of prior smoking cessation on postoperative pulmonary complications in the elderly: secondary analysis of a prospective cohort study. Eur J Anaesthesiol 2018; 34:853-854. [PMID: 29087999 DOI: 10.1097/eja.0000000000000720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Valsangkar N, Salfity HV, Timsina L, Ceppa DP, Ceppa EP, Birdas TJ. Operative time in esophagectomy: Does it affect outcomes? Surgery 2018; 164:866-871. [DOI: 10.1016/j.surg.2018.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/29/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
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Bronheim RS, Oermann EK, Bronheim DS, Caridi JM. Revised Cardiac Risk Index versus ASA Status as a Predictor for Noncardiac Events After Posterior Lumbar Decompression. World Neurosurg 2018; 120:e1175-e1184. [PMID: 30218801 DOI: 10.1016/j.wneu.2018.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/01/2018] [Accepted: 09/04/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) was designed to predict risk for cardiac events after noncardiac surgery. However, there is a paucity of literature that directly addresses the relationship between RCRI and noncardiac outcomes after posterior lumbar decompression (PLD). The objective of this study is to determine the ability of RCRI to predict noncardiac adverse events after PLD. METHODS The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing PLD from 2006 to 2014. Multivariate and receiver operating characteristic analysis was used to identify associations between RCRI and postoperative complications. RESULTS A total of 52,066 patients met the inclusion criteria. Membership in the RCRI=1 cohort independently predicted unplanned intubation, ventilation >48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection (UTI), sepsis, septic shock, and readmission. Membership in the RCRI=2 cohort independently predicted for superficial surgical site infection, pneumonia, unplanned intubation, ventilation >48 hours, bleeding transfusion, progressive renal insufficiency, acute renal failure, UTI, sepsis, septic shock, and readmission. Membership in the RCRI=3 cohort independently predicted unplanned intubation (odds ratio [OR], 11.8), ventilation >48 hours (OR, 23.0), acute renal failure (OR, 84.5), and UTI (OR, 3.6). RCRI had a poor discriminative ability (DA) (area under the curve = 0.623), and American Society of Anesthesiologists status had a fair DA (area under the curve = 0.770) to predict a composite of noncardiac complications. CONCLUSIONS RCRI was predictive of a wide range of noncardiac complications after PLD but had a diminished DA to predict a composite of any noncardiac complication than did American Society of Anesthesiologists score. Consideration of the RCRI as a component of preoperative surgical risk stratification can minimize patient morbidity and mortality after lumbar decompression.
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Affiliation(s)
- Rachel S Bronheim
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David S Bronheim
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Azmy MC, Bansal AP, Yip C, Kalyoussef E. Is quicker better? A NSQIP analysis of anesthesia time and complications following tracheostomy placement. Am J Surg 2018; 216:805-808. [PMID: 30286940 DOI: 10.1016/j.amjsurg.2018.07.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/26/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Increased anesthesia time may lead to respiratory complications in patients receiving tracheostomy, which contributes to patient morbidity. METHODS The American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases of planned tracheostomy (CPT 31600) from 2005 to 2012. Patients were stratified into quintiles based on anesthesia duration. Pearson's chi square, Fischer's exact test, one-way ANOVA, and multivariate regression were used to determine the association between patient characteristics with pneumonia and ventilator dependence. RESULTS Out of 752 patients, 83 patients experienced post-operative pneumonia, and 166 experienced ventilator dependence. Following multivariate regression analysis, anesthesia quintiles were not significantly associated with pneumonia or ventilator dependence. Age (OR 1.03, 95% CI 1.00-1.05, P = .032), dyspnea (OR 2.21, 95% CI 1.18-4.13; P = .013), pre-operative ventilator dependence (OR 3.08, 95% CI 1.19-7.98; P = .020), and sepsis (OR 6.68, 95% CI 3.19-14.0; P < .001) remained as significant predictors of post-operative ventilator dependence. CONCLUSIONS Faster may not be better-- prolonged anesthesia time does not increase the risk of post-operative pneumonia or ventilator dependence in patients receiving a planned tracheostomy in the operating room.
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Affiliation(s)
- Monica C Azmy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amy P Bansal
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Candice Yip
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Evelyne Kalyoussef
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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Batista Rodríguez G, Balla A, Fernández-Ananín S, Balagué C, Targarona EM. The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review. Surg Innov 2018; 25:400-412. [PMID: 29781362 DOI: 10.1177/1553350618775539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery. METHODS A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed. RESULTS A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery. CONCLUSIONS The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.
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Affiliation(s)
- Gabriela Batista Rodríguez
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,2 Unidad de Cirugía Oncológica, Departamento de Hemato-Oncologia, Hospital Dr. Rafael A. Calderón Guardia, Caja Costarricense del Seguro Social, San José, Costa Rica
| | - Andrea Balla
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,3 Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Sonia Fernández-Ananín
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Carmen Balagué
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Eduard M Targarona
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
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Yoshida N, Nakamura K, Kuroda D, Baba Y, Miyamoto Y, Iwatsuki M, Hiyoshi Y, Ishimoto T, Imamura Y, Watanabe M, Baba H. Preoperative Smoking Cessation is Integral to the Prevention of Postoperative Morbidities in Minimally Invasive Esophagectomy. World J Surg 2018. [DOI: 10.1007/s00268-018-4572-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Burton BN, Khoche S, A'Court AM, Schmidt UH, Gabriel RA. Perioperative Risk Factors Associated With Postoperative Unplanned Intubation After Lung Resection. J Cardiothorac Vasc Anesth 2018; 32:1739-1746. [PMID: 29506893 DOI: 10.1053/j.jvca.2018.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION None. MEASUREMENT AND MAIN RESULTS The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.
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Affiliation(s)
- Brittany N Burton
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, California; Department of Biomedical Informatics, University of California, San Diego, San Diego, California.
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Zhang GH, Wang W. Effects of sevoflurane and propofol on the development of pneumonia after esophagectomy: a retrospective cohort study. BMC Anesthesiol 2017; 17:164. [PMID: 29202701 PMCID: PMC5715630 DOI: 10.1186/s12871-017-0458-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/24/2017] [Indexed: 12/01/2022] Open
Abstract
Background Postoperative pneumonia (PP) is one of the common complications following esophagectomy and associated with poor short- and long-term outcomes. Sevoflurane and propofol, which have inflammatory-modulating effects, are common used general anesthetics. This study aimed to compare the effects of anesthesia with sevoflurane and propofol on the development of PP after esophageal surgery for cancer. Methods The electronic medical records of patients who underwent elective esophagectomy between July 2013 and July 2016 were reviewed. We conducted univariate and multivariate logistics analysis and propensity score matching analysis to compare the effect of sevoflurane and propofol on the incidence of PP and to identify the risk factors for PP after esophagectomy. Results Overall, the incidence of postoperative pneumonia was 9.5%. There was no significant difference in the rates of PP between sevoflurane group and propofol group either before or after propensity score matching (9.6% vs 8.0%, P = 0.606; 7.7% vs 6.4%, P = 0.754, respectively). Univariate and multivariate analysis revealed that alcohol use (OR 1.513; 95% CI 1.062–2.156), surgical procedure (Sweet: referent; Ivor-Lewis: OR 1.993; 95% CI 1.190–3.337; Three-incision: OR 1.878; 95% CI 1.296–2.722) and surgeon experience (high-volume: referent; low-volume: OR 1.525; 95% CI 1.090–2.135) were significant risk factors of postoperative pneumonia. Conclusions Sevoflurane did not differ from propofol in terms of affecting the risk of PP development after esophagectomy.
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Affiliation(s)
- Guo-Hua Zhang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli Road, Chaoyang District, Beijing, 100021, China.
| | - Wen Wang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli Road, Chaoyang District, Beijing, 100021, China
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Yan T, Liang XQ, Wang T, Li WO, Li HJ, Zhu SN, Wang DX. Prophylactic penehyclidine inhalation for prevention of postoperative pulmonary complications in high-risk patients: study protocol of a randomized controlled trial. Trials 2017; 18:571. [PMID: 29183393 PMCID: PMC5706155 DOI: 10.1186/s13063-017-2315-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 11/06/2017] [Indexed: 11/20/2022] Open
Abstract
Background Postoperative pulmonary complications (PPCs) are major causes of morbidity, mortality, and prolonged hospital stay in patients after surgery. Using effective strategies to prevent its occurrence is essential to improve outcome. However, despite various efforts, the incidence of PPCs remains elevated in high-risk patients. Anticholinergic inhalation is used to reduce high airway resistance and improve pulmonary function; it may be helpful to decrease the risk of PPCs. Penehyclidine is a long-acting anticholinergic agent which selectively blocks M1 and M3 receptors. We hypothesize that, in high-risk patients, prophylactic penehyclidine inhalation may decrease the incidence of PPCs. Methods This is a randomized, double-blind, placebo-controlled trial with two parallel arms. A total of 864 patients at high risk of PPCs will be enrolled and randomized to receive prophylactic inhalation of either penehyclidine or placebo (water for injection). Study drug inhalation will be administered from the night (7 pm) before surgery until the second day after surgery, in an interval of every 12 hours. The primary outcome is the incidence of PPCs within 30 days after surgery. Secondary outcomes include the time to onset of PPCs (from end of surgery to first diagnosis of PPCs), the number of PPCs (indicates the number of diagnosed individual PPCs), the incidence of postoperative extrapulmonary complications, the length of stay in hospital after surgery, and the 30-day all-cause mortality. Discussion Results of the present study will provide evidence to guide clinical practice in using prophylactic inhalation of an anticholinergic to prevent PPCs in high-risk patients. Trial registration The study was registered prospectively in Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPC-15006603) on 14 May 2015 and retrospectively in ClinicalTrials.gov (NCT02644876) on 30 December 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2315-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ting Yan
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Xin-Quan Liang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Tong Wang
- Department of Anesthesiology, Aerospace Central Hospital, No.15 Yuquan Street, Haidian District, Beijing, 100049, China
| | - Wei-Ou Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China.
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Xu J, Hu J, Yu P, Wang W, Hu X, Hou J, Fang S, Liu X. Perioperative risk factors for postoperative pneumonia after major oral cancer surgery: A retrospective analysis of 331 cases. PLoS One 2017; 12:e0188167. [PMID: 29135994 PMCID: PMC5685601 DOI: 10.1371/journal.pone.0188167] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/01/2017] [Indexed: 11/25/2022] Open
Abstract
Objective Postoperative pneumonia (POP) is common and results in prolonged hospital stays, higher costs, increased morbidity and mortality. However, data on the incidence and risk factors of POP after oral and maxillofacial surgery are rare. This study aims to identify perioperative risk factors for POP after major oral cancer (OC) surgery. Methods Perioperative data and patient records of 331 consecutive subjects were analyzed in the period of April 2014 to March 2016. We individually traced each OC patient for a period to discharge from the hospital or 45 days after surgery, whichever occur later. Results The incidence of POP after major OC surgery with free flap construction or major OC surgery was 11.6% or 4.5%, respectively. Patient-related risk factors for POP were male sex, T stage, N stage, clinical stage and preoperative serum albumin level. Among the investigated procedure-related variables, incision grade, mandibulectomy, free flap reconstruction, tracheotomy, intraoperative blood loss, and the length of the operation were shown to be associated with the development of POP. Postoperative hospital stay was also significantly related to increased incidence of POP. Using a multivariable logistic regression model, we identified male sex, preoperative serum albumin level, operation time and postoperative hospital stay as independent risk factors for POP. Conclusion Several perioperative risk factors can be identified that are associated with POP. At-risk oral cancer patients should be subjected to intensified postoperative pulmonary care.
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Affiliation(s)
- Jieyun Xu
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Jing Hu
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Pei Yu
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Weiwang Wang
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Xingxue Hu
- Department of Immunology and Infectious Diseases, the Forsyth Institute, Cambridge, Massachusetts, United States of America
- Division of General Practice and Materials Science, the Ohio State University College of Dentistry, Columbus, Ohio, United States of America
| | - Jinsong Hou
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Silian Fang
- Department of Oral and Maxillofacial Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (SF); (XL)
| | - Xiqiang Liu
- Department of Oral Maxillofacial–Head & Neck Oncology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
- * E-mail: (SF); (XL)
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Glatz T, Höppner J. Is There a Rationale for Structural Quality Assurance in Esophageal Surgery? Visc Med 2017; 33:135-139. [PMID: 28560229 DOI: 10.1159/000458454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Advances regarding perioperative mortality rates and oncological outcomes after esophagectomy have been reported extensively by specialized high-volume centers in Europe and the USA over the last decade. However, recent database analyses reveal that the perioperative mortality of esophagectomy remains high in these countries, indicating a discrepancy between surgical quality in baseline hospitals and specialized centers. METHODS This article provides an overview over the existing literature on the correlation between structural quality, procedural volume, and surgical outcome in e- sophageal surgery. RESULTS Structural, procedural and outcome measures can be used to assess the quality of surgical treatment and perioperative management. Surgical procedures on the esophagus for both benign and malignant diseases are rare and typically associated with high perioperative morbidity and mortality. Usually, direct outcome measures do not provide enough statistical power to actually identify differences in surgical quality between hospitals, making structural quality measures the only feasible parameter to compare the quality of e- sophageal surgery among different centers. Several analyses from different countries have shown a strong correlation between hospital volume and postoperative mortality. Data from countries in which esophageal surgery has been centralized indicate beneficial effects of a centralized health care system on postoperative mortality after esophagectomy. Additionally, only high-volume centers generally provide optimal preoperative and postoperative management and comprehensive access to modern multimodal treatment. In Germany, esophageal surgery is still decentralized, but hospitals performing complex esophageal procedures have to fulfill minimum caseload requirements of 10 cases per year. In practice, these requirements are not met by the majority of hospitals and a detrimental effect on the achieved surgical outcomes can be noted. CONCLUSION Therefore, we conclude that structural quality assurance is crucial to further reduce postoperative morbidity after esophageal surgery and to improve long-term results.
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Affiliation(s)
- Torben Glatz
- Department of General and Visceral Surgery, University of Freiburg, Freiburg i. Br., Germany
| | - Jens Höppner
- Department of General and Visceral Surgery, University of Freiburg, Freiburg i. Br., Germany
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