The present study demonstrates high lymph node yields are possible after transthoracic esophagectomy with en bloc 2-field lymphadenectomy in patients post neoadjuvant chemotherapy. This allows excellent postoperative staging. Furthermore, the extent of lymphadenectomy must be correlated with node location, which may have important implications in patients who have a less extensive lymphadenectomy.
Background:In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy.Methods:Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes.Results:A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis.Conclusions:In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.
Introduction Operable oesophagogastric adenocarcinoma management in the UK includes three cycles of neoadjuvant chemotherapy (NAC) followed by resection. Determination of oxygen uptake at the anaerobic threshold (AT) with cardiopulmonary exercise testing (CPET) is used to objectively measure cardiorespiratory reserve. Oxygen uptake at AT predicts perioperative risk, with low values associated with increased morbidity. Previous studies indicate NAC may have a detrimental impact on cardiorespiratory reserve. Methods CPET was completed by 30 patients before and after a standardised NAC protocol. The ventilatory AT was determined using the V-slope method, and the peak oxygen uptake and ventilatory equivalents for carbon dioxide measured. Median AT before and after chemotherapy was compared using a paired Student’s t-test. Results Median oxygen uptake at AT pre- and post-NAC was 13.9±3.1 ml/kg/min and 11.5±2.0 ml/kg/min, respectively. The mean decrease was 2.4 ml/kg/min (95% confidence interval [CI] 1.3–3.85; p<0.001). Median peak oxygen delivery also decreased by 2.17 ml/kg/min (95% CI 1.02–3.84; p=0.001) after NAC. Ventilatory equivalents were unchanged. Conclusions This reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after NAC. Patients with lower cardiorespiratory reserve have increased postoperative morbidity and mortality. Preventing this decrease in cardiorespiratory reserve during chemotherapy, or optimising the timing of surgical resection after recovery of AT, may allow perioperative risk-reduction.
Oesophagectomy is a technically-demanding operation associated with a high level of morbidity. We analysed the association of pre-operative variables, including those from cardiopulmonary exercise testing, with complications (logistic regression) and survival and length of stay (Cox regression) after scheduled transthoracic oesophagectomy in 273 adults, in isolation and on multivariate testing (maximum Akaike information criterion). On multivariate analysis, any postoperative complication was associated with ventilatory equivalents for carbon dioxide, odds ratio (95%CI) 1.088 (1.02-1.17), p = 0.018. Cardiorespiratory complications were associated with FEV and pre-operative background survival (in an analogous group without cancer), odds ratios (95%CI) 0.55 (0.37-0.80), p = 0.002 and 0.89 (0.82-0.96), p = 0.004, respectively. Survival was associated with the ratio of expected-to-observed ventilatory equivalents for carbon dioxide and predicted postoperative survival, hazard ratios (95%CI) 0.17 (0.03-0.91), p = 0.039 and 0.96 (0.90-1.01), p = 0.076. Length of hospital stay was associated with FVC, hazard ratio (95%CI) 1.38 (1.17-1.63), p < 0.0001.
These findings demonstrate that patient outcomes are not compromised by supervised trainee involvement in transthoracic esophagectomy. Training is an essential role of all surgical units and training data should be more widely reported especially in areas of high-risk surgery.
There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.
Background. Esophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence. Objective. The aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer. Methods. Consecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single highvolume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien-Dindo grade III/IV complications. Results. This study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days; p \ 0.001) and prolonged hospital stay (median 43 vs. 27 vs. 15 days; p \ 0.001) compared with NSL or no AL. There were no significant differences in number of lymph nodes harvested and rates of R1 resection between groups. OS and RFS were not affected by either NSL or SEAL, and Cox multivariate regression showed NSL and SEAL were not independently associated with OS and RFS. Sensitivity analysis in patients receiving neoadjuvant therapy followed by esophagectomy demonstrated similar findings. Conclusion. These results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact. Esophagectomy remains a key component of treatment for patients with potentially curable esophageal cancer. While mortality levels from the procedure have fallen dramatically over the last 30 years, esophagectomy is still associated with high levels of morbidity. 1-3 Anastomotic leak (AL) is a commonly seen complication that has historically been associated with high mortality rates. 4 The Esophagectomy Complications Consensus Group (ECCG) defined AL as a full-thickness defect involving the esophagus, anastomosis, staple line or conduit, irrespective of the presentation or method of identification. 5 The classification further divided leaks into the management strategy employed: type I, those that require no change in treatment; type II, leaks that require intervention, but not surgery; and type III, leaks that require surgical intervention. The incidence of AL has been reported at between 3 and 30%. 6,7 This can result in a prolonged hospital stay, a need for reoperation, anastomotic stricturing that requires repeated dilations, and potentially poorer long-term survival. 8,9 A French multicenter study, which defined severe
Summary Background The COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center. Methods All patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated. Results Overall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications. Conclusion Care must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care.
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