BackgroundZenker's diverticulum (ZD) is a protrusion of the pharyngeal mucosa and submucosa through Killian's triangle, between the inferior pharyngeal constrictor muscle and the cricopharyngeal muscle. The underling mechanism of formation is the pulsion against a dyscinetic upper esophageal sphincter (UES). It is a rare disorder and mostly affects elderly people, but still, it is the most frequent esophageal diverticulum. Its incidence is reported to be

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Backgrounds and aim oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (PODH) represents a potentially life-threatening complication with an underestimated occurrence rate and unclear related risk factors. Aim of this study was to identify possible risk factors of PODH and results of surgical treatment from experience of two tertiary referral centers. Methods all patients affected by a clinically resectable oesophageal cancer (any T, any N and M0) and submitted to Ivor-Lewis oesophagectomy, regardless of technique (open, hybrid or totally minimally invasive) between 1997 and 2017 at our Institutions were selected for this study. Demographic, clinical pre, intra, post-operative, and follow-up data were prospectively collected in an electronic database. A retrospective analysis was conducted in order to evaluate the incidence of PODH, associated risk factors and surgical repair results. Results 414 patients underwent Ivor-Lewis oesophagectomy for cancer in the study period and 22 (5.3%) developed PODH at a median follow-up time of 16 months (6 - 177). Surgical repair was mainly conducted by laparoscopic approach (77%) with a conversion rate of 24%. Postoperative morbidity was 22.7% and mortality 4.5%. Median postoperative hospital stay was 6 days (2 - 95). 3 recurrences (13.6%) occurred at a median follow-up time of 10.1 months. A wide univariate analysis identified statistically significant associations between PODH occurrence and the administration of preoperative chemoradiation, a complete pathological response (CPR) and a harvested lymph-nodes number (HLN) larger than 33 (p-value 0.016, 0.001 and 0.024 respectively). A significant association with a large HLN number was confirmed by the multivariable analysis (0.026) along with CPR which could however be considered as a longer survival-related bias. Conclusions The minimally invasive surgery and the neoadjuvant chemoradiation, in contrast to results of other authors, in our experience are not associated with PODH development, while a HLN number larger than 33 resulted to be an independent risk factor, probably mirroring the extent of surgical demolition in oesophagectomy. Surgical repair can be safely and effectively performed trough laparoscopy but recurrences can frequently occur.

Background and aims ERAS principles have been applied even in oesophageal surgery, however low compliance and high rates of deviation from protocols are often reported. Aim of this study was to assess whether ERAS protocol deviation and other perioperative factors could be associated with a delayed discharge. Methods Patients who underwent esophagectomy at our Institution between 2014 and 2017 were included in the study. All patients were managed according to our perioperative ERAS protocol. In-hospital deaths were excluded. All data were prospectively entered in an electronic database. The 8th postoperative day (POD) was considered as the ideal day for discharge and therefore our outcome. A retrospective analysis of most relevant ERAS items and clinical features was conducted in order to identify variables positively or negatively associated to a delayed discharge. Variables associated with our outcome were exploited to build a score able to predict delayed discharge. An initial validation of the accuracy of the score was carried out on a separate patients’ sample. A χ2 test assessed association between outcome and categorical variables. Adapted standardized residuals of multilevel categorical variables allowed a dichotomous division. A new χ2 test confirmed the association. A ROC curve approach evaluated the role of continuous variables as markers of hospitalization longer than outcome. A χ2 test assessed the presence of association between the dichotomized variable and outcome. Backward logistic binary regression selected significant predictors with a selection criteria of p-value of <.05. Results 286 esophagectomies were included in the study. ASA score *** 3, surgery duration *** 255 minutes and failure to mobilize within 24 hours were associated with a delayed discharge. “Hybrid” oesophagectomy was linked to a discharge within the target day. The logistic regression model was statistically significant (p < 0,001) and correctly classified 81,9% of cases. Sensitivity was 96,6%. Positive predictive value was 83,6% and negative 45,4%. The predictive score system, once applied to control population, correctly identified 100% of those discharged after 8th POD. Conclusions Our results seem to be clinically meaningful. All these parameters can be retrieved within the first 24 hours. The initial validation revealed good predictive properties.