Curative Surgery For Esophageal Cancer Research Articles

588. EFFICACY OF INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING DURING MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATIONWIDE INPATIENT COHORT STUDY

Abstract Background Lymphadenectomy around the recurrent laryngeal nerve (RLN) is an essential part of curative surgery for esophageal cancer. The rate of lymph node metastasis around the RLN is extremely high, and postoperative RLN palsy could lead to a poor prognosis in patients with esophageal cancer. Although several single-center studies have shown that intraoperative nerve monitoring (IONM) can avoid RLN palsy, this has not been confirmed in a large-scale multicenter study. This study was performed to evaluate whether intraoperative nerve monitoring IONM can reduce postoperative RLN palsy during minimally invasive esophagectomy (MIE) for esophageal cancer using a national database. Methods We retrieved data of patients with esophageal cancer who underwent MIE involving thoracoscopic or robotic esophagectomy with IONM (502 patients) and without IONM (4,353 patients) at 348 hospitals from April 2020 to March 2022 from the Diagnosis Procedure Combination database in Japan. We compared the frequency of postoperative RLN palsy and respiratory complications between the IONM (+) group and IONM (−) group using propensity score-matching (PSM) analysis. The propensity score was estimated using multivariable logistic regression models including age, sex, Body Mass Index, Brinkman index, Activities of Daily Living, comorbidities at admission, clinical TNM classification, approach of MIE, and hospital case volume with reference to previous studies of IONM. Results After PSM, the standardized bias was <10% for all covariates, which indicated improved balance in the covariates between the matched pairs. With 1-to-1 matching, 501 pairs (1,002 cases) were created between the IONM (+) and (−) groups. The postoperative RLN palsy rate was significantly lower in the IONM (+) than (−) group (odds ratio, 0.24; 95% confidence interval [CI], 0.13–0.46). The respiratory complication rate was also significantly lower in the IONM (+) than (−) group (odds ratio, 0.66; 95% CI, 0.45–0.97). The anesthesia time was significantly longer in the IONM (+) group (regression coefficient, 60.1 minutes; 95% CI, 44.2–76.9). The length of postoperative hospitalization tended to be shorter in the IONM (+) than (−) group (regression coefficient, −1.39 days; 95% CI, −3.91 to 1.14). Conclusion This nationwide cohort study showed that IONM during MIE for esophageal cancer can reduce postoperative RLN palsy and respiratory complications.

492. OUTCOMES OF ESOPHAGECTOMY IN THE ELDERLY- IS IT WORTH THE EFFORT?

Abstract Background Esophageal cancer is the sixth most common cancer in India and most patients are diagnosed at locally or loco-regionally advanced stages. Multimodal management offers the best chance of cure, with surgery being the cornerstone. With improved life expectancy, elderly patients with esophageal cancer are being referred for surgery more frequently. Although recent studies have shown encouraging outcomes, increased post-operative complications are common. The aim of our study was to evaluate morbidity and survival in patients above 70 years undergoing curative surgery for esophageal cancer from 2011 to 2021 at our centre. Methods Of 2291 patients undergoing esophagectomy, 122 were above 70 years, ten were inoperable. Mean age was 73.3 years (70-84 years), with 78% males and 83% squamous cell carcinoma, most common location being lower-third (63.6%). Of the 110 patients, 80 (72.7%) received neoadjuvant treatment, 68(61.8%) were ASA grade II or more. McKneown’s approach was common, utilized in 55%, of which minimally invasive in 53%, with Ivor- Lewis, left thoraco-abdominal and transhiatal approaches in the rest. Mean blood loss was 350 ml, with mean operative time of 270 minutes and circumferential positivity rate of 12.7%. Results The mean ICU stay was 1 day, with the mean hospital stay being 13 days. Almost half (49%) had Clavien-Dindo grade III or higher morbidity, with pulmonary complications seen in 27%. Anastomotic leakage was seen in 20/110 (18%), with only 2 patients needing an intervention. 30-day mortality was 8.2%. Recurrences were seen in 21 patients, anastomotic and regional recurrences in 6, distant in 6, regional with distant in 9. The median recurrence free survival was 26 months with 3-year RFS of 43.7%. With a median follow-up of 25 months, median overall survival was 30 months and 3-year OS was 45.3%. Conclusion Despite higher post-operative morbidity and mortality, elderly patients have reasonable recurrence free and overall survival outcomes with curative surgery. With continuing refinements in prehabilitation, operative techniques, wider adoption of minimally invasive surgery, intra-operative management and post-operative care, early post-operative outcomes are likely to improve further. Elderly patients with resectable esophageal cancer should not be denied surgery.

Intraoperative Recurrent Laryngeal Nerve Monitoring for Esophagectomy: A National Cohort Study

BackgroundLymphadenectomy around the recurrent laryngeal nerve (RLN) is an essential part of curative surgery for esophageal cancer. Although several single-center studies have shown that intraoperative nerve monitoring (IONM) can avoid RLN palsy, this has not been confirmed in a large-scale multicenter study. This study used a national database to evaluate whether IONM can reduce postoperative RLN palsy during minimally invasive esophagectomy (MIE) for esophageal cancer. MethodsWe retrieved data of patients with esophageal cancer who underwent 3-field thoracoscopic or robotic MIE with cervical anastomosis with IONM(+) (502 patients) and without IONM(−) (4353 patients) from April 2020 to March 2022 from the Diagnosis Procedure Combination database in Japan. We used propensity score-matching analysis to compare the frequency of postoperative RLN palsy and respiratory complications between the IONM(+) group and IONM(−) group. ResultsThe postoperative RLN palsy rate was significantly lower in the IONM(+) than IONM(−) group (odds ratio, 0.24; 95% CI, 0.13-0.46). The respiratory complication rate was also significantly lower in the IONM(+) than in the IONM(−) group (odds ratio, 0.66; 95% CI, 0.45-0.97). The anesthesia time was significantly longer in the IONM(+) group (regression coefficient, 60.1 minutes; 95% CI, 44.2-76.9 minutes). The length of postoperative hospitalization tended to be shorter in the IONM(+) than in the IONM(−) group (regression coefficient, −1.39 days; 95% CI, −3.91 to 1.14). ConclusionsThis national cohort study showed that IONM during 3-field MIE for esophageal cancer was associated with a reduction of postoperative RLN palsy and respiratory complications.

Application of neoadjuvant chemoradiotherapy and neoadjuvant chemotherapy in curative surgery for esophageal cancer: A meta-analysis.

The effectiveness of neoadjuvant therapy in esophageal cancer (EC) treatment is still a subject of debate. To compare the clinical efficacy and toxic side effects between neoadjuvant chemoradiotherapy (nCRT) and neoadjuvant chemotherapy (nCT) for locally advanced EC (LAEC). A comprehensive search was conducted using multiple databases, including PubMed, EMBASE, MEDLINE, Science Direct, The Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Journal Database, and Chinese Biomedical Literature Database Article. Studies up to December 2022 comparing nCRT and nCT in patients with EC were selected. The analysis revealed significant differences between nCRT and nCT in terms of disease-free survival. The results indicated that nCRT provided better outcomes in terms of the 3-year overall survival rate (OSR) [odds ratio (OR) = 0.95], complete response rate (OR = 3.15), and R0 clearance rate (CR) (OR = 2.25). However, nCT demonstrated a better 5-year OSR (OR = 1.02) than nCRT. Moreover, when compared to nCRT, nCT showed reduced risks of cardiac complications (OR = 1.15) and pulmonary complications (OR = 1.30). Overall, both nCRT and nCT were effective in terms of survival outcomes for LAEC. However, nCT exhibited better performance in terms of postoperative complications.

433. INTRAOPERATIVE ICG-IMAGING AS A TOOL TO ASSESS PERFUSION IN THE GASTRIC CONDUIT

Abstract Background In curative surgery for esophageal cancer a gastric conduit is often used to replace the resected esophagus. Anastomotic leakage (AL) is a serious complication. Sufficient perfusion in the gastric conduit is critical for the anastomosis. The aim of this pilot study was to investigate the feasibility of intraoperative indocyanine green (ICG) and near-infrared fluorescent imaging as a tool to assess perfusion of the gastric conduit in order to prevent postoperative AL. Methods Patients undergoing esophageal resection at Umeå University Hospital were invited to participate in this prospective study during 2017–2022. The surgery performed was open Ivor-Lewis esophagectomy. ICG was administered intraoperatively and video footage of the near-infrared fluorescence was recorded. The time from injection until visualized fluorescence in the gastric conduit was measured, as well as the intensity of the fluorescence in the gastric conduit. A loop of jejunum was used as control and the quotient between the measurement in the jejunal loop and in the gastric conduit was used for objective assessment. Results 50 individuals were included. 46 patients had received neoadjuvant chemoradiotherapy and 3 had received chemotherapy only. 32 patients had video footages that were possible to assess as described above. Of these 11 had AL. No differences were demonstrated between patients with AL and those without, neither regarding time to fluorescence (p = 0.42), nor intensity (p = 0.72). Conclusion AL is a serious complication to esophageal surgery with a high incidence. Perfusion assessment of the gastric conduit using ICG has emerged as a promising technique to reduce AL. In this pilot study we developed two techniques to evaluate the perfusion in an objective manner, whilst none of these seem to be able to predict postoperative AL.

Influence of the Oral Health Assessment Tool Score on Survival of Patients With Esophageal Cancer.

We investigated the influence of the preoperative Oral Health Assessment Tool (OHAT) score on the outcomes of patients with esophageal cancer after curative surgery. This study included 90 patients with esophageal cancer who underwent curative surgery and who were screened with the OHAT between 2008 and 2021. The OHAT consists of eight categories with three possible scores. The risk factors for 5-year overall survival (OS) and recurrence-free survival (RFS) were identified. Patients were divided into healthy (n=42) and unhealthy (n=48) groups. The OHAT score was identified as a significant risk factor for postoperative pneumonia (11.9% vs. 43.8%, p=0.001) and postoperative hospital stay (20.5 days vs. 50.1 days, p=0.042). The 5-year OS rate after surgery was 71.2% in the healthy group and 43.2% in the unhealthy group, which was a significant difference (p=0.015). A multivariate analysis showed that a high OHAT score was a significant independent factor for 5-year OS (p=0.034). The OHAT score was a useful prognostic marker in patients who underwent curative surgery for esophageal cancer. To improve the oncological outcomes of patients with esophageal cancer, it is necessary to carefully plan perioperative oral/dental care using the OHAT score.

Is Hypertrophic or Keloid Wound Scar a Risk Factor for Stricture at Esophagogastric Anastomosis Site after Esophageal Cancer Operation?

Anastomotic stricture at the esophagus and the conduit anastomosis site after the surgical resection of esophageal cancer is relatively common. This study examined whether a hypertrophic scar or keloid formation at a surgical wound is related to an anastomotic stricture. From March 2007 to July 2017, 59 patients underwent curative surgery for esophageal cancer. In 38 patients, end-to-end anastomosis (EEA) of the esophagus and the conduit was performed using EEA 25 mm. A hypertrophic wound scar was defined when the width of the midline laparotomy wound scar exceeded 2 mm. The relationship between the hypertrophic scar and stricture and the other risk factors for anastomotic stricture in these 38 patients was analyzed. Of the 38 patients, eight patients (21.1%) had an anastomotic stricture, and a hypertrophic skin scar was observed in 14 patients (36.8%). Univariate analysis revealed lower BMI and hypertrophic scars as risk factors (p=0.032, p=0.001 respectively). Multivariate analysis revealed a hypertrophic scar as an independent risk factor for an anastomotic stricture (p=0.010, OR=27.06, 95% CI 2.19-334.40). Hypertrophic wound scars can be a risk factor for anastomotic stricture after surgery for esophageal cancer. An earlier prediction of anastomotic stricture by detecting hypertrophic wound healing in patients undergoing esophagectomy may improve the patients' quality of life and surgical outcomes by earlier treatments.

Low Preoperative Albumin-to-Globulin Ratio Is a Marker of Poor Prognosis in Patients With Esophageal Cancer.

Recent studies have reported that the albumin-to-globulin ratio (AGR) may be a useful inflammatory-nutritional biomarker to predict postoperative complications and poor prognosis in various types of patients with cancer. However, its prognostic value in patients with esophageal cancer is still unclear. We aimed to examine the utility of the AGR for predicting the short- and long-term outcomes in patients with esophageal cancer who underwent curative resection. This was a retrospective cohort analysis reviewing the medical records of consecutive patients who underwent esophagectomy for clinical stage I to III esophageal cancer at Yokohama City University. A total of 105 patients were identified between 2005 and 2018. The overall survival (OS), recurrence-free survival (RFS), and postoperative complication rates were compared between patients with high AGR (>1.48) and those with low AGR (≤1.48) group. A total of 57 and 48 patients were classified into the high and low AGR groups, respectively. There was no significant difference between the two groups in the rate of overall postoperative complications of more than Clavien-Dindo grade 3 (50.9% vs. 54.2%, p=0.85). The long-term findings showed that 5-year OS and RFS rates were significantly better for the group with a high AGR (67.2% vs. 33.8%, p<0.001 and 51.6% vs. 28.5%, p=0.003, respectively). This study suggests that a low preoperative AGR is a risk factor for poor RFS and OS in patients who are planning to undergo curative surgery for esophageal cancer. AGR may be a useful biomarker for establishing treatment strategies to improve patients' survival.

Clinical Factors and Outcomes of Octogenarians Receiving Curative Surgery for Esophageal Cancer

BackgroundThe incidence of esophageal cancer is increasing in the United States. Although neoadjuvant therapy (NAT) for locally advanced cancers followed by surgical resection is the standard of care, there are no clearly defined guidelines for patients aged ≥79 y. MethodsQuery of an institutional review board–approved database of 1031 esophagectomies at our institution revealed 35 patients aged ≥79 y from 1999 to 2017 who underwent esophagectomy. Age, gender, tumor location, histology, clinical stage, Charlson Comorbidity Index (CCI), NAT administration, pathologic response rate to NAT, surgery type, negative margin resection status, postoperative complications, postoperative death, length of stay, 30- and 90-d mortality, and disease status parameters were analyzed in association with clinical outcome. ResultsThe median age of the octogenarian cohort was 82.1 y with a male preponderance (91.4%). American Joint Committee on Cancer clinical staging was stage I for 20% of patients, stage II for 27% of patients, and stage III for 50% of patients, which was not statistically significant compared with the younger cohort (P = 0.576). Within the octogenarian group, 54% received NAT compared with 67% in the younger group (P = 0.098). There was no difference in postoperative complications (P = 0.424), postoperative death (P = 0.312), and recurrence rate (P = 0.434) between the groups. However, CCI was significantly different between the octogenarian and nonoctogenarian cohort (P = 0.008), and octogenarians had shorter overall survival (18 versus 62 mo, P<0.001). None of the other parameters assessed were associated with clinical outcomes. ConclusionsCurative surgery is viable and safe for octogenarians with esophageal cancer. Long-term survival was significantly shorter in the octogenarian group, suggesting the need for better clinical selection criteria for esophagectomy after chemoradiation and that identification of complete responders for nonoperative management is warranted.

Risk Factors for Postoperative Pneumonia After Esophagectomy for Esophageal Cancer

Few studies have investigated the risk factors for postoperative pneumonia after esophageal cancer surgery. The aim of the present study was to identify risk factors of postoperative pneumonia after esophagectomy for esophageal cancer. This study included 122 patients who underwent curative surgery for esophageal cancer between January 2005 and September 2018. The rate of postoperative pneumonia was measured by the revised Uniform Pneumonia Score. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for postoperative pneumonia. Postoperative pneumonia was found in 34 of the 122 patients (27.9%). Among the factors examined (age, gender, preoperative chemotherapy status, operative type, operative duration, blood loss, lymph node dissection, smoking habit, and alcohol habit), the age (p = 0.038) and operative duration (p = 0.035) were identified as significant independent risk factors for postoperative pneumonia in the univariate and multivariate analyses. The incidence of postoperative pneumonia was 40% (22 of 55) in patients ≥ 70 years old and 17.9% (12 of 67) in those < 70 years old. The incidence of postoperative pneumonia was 45.2% (28 of 62) in the operative duration ≥ 570 min group and 10.0% (6 of 60) in the operative duration < 570 min group. The age and operative duration were risk factors for postoperative pneumonia in patients who underwent curative esophagectomy for esophageal cancer. To improve the survival of patients with esophageal cancer, it is necessary to carefully plan the surgical procedure, perioperative care, and surgical strategy.

The Lymph Node Ratio Is an Independent Prognostic Factor in Esophageal Cancer Patients Who Receive Curative Surgery.

We investigated the clinical impact of the lymph node ratio (LNR) on overall survival (OS) and recurrence-free survival (RFS) in esophageal cancer patients who underwent curative surgery. One hundred twenty patients who underwent curative surgery for esophageal cancer between 2005 and 2017 were included in this study. The LNR was defined as the ratio of the number of metastatic lymph nodes (LNs) to the total number of harvested LNs. A lymph node ratio of 10% was regarded as the optimal critical point for classification based on the overall survival rate. The 3-year and 5-year OS rates were 65.5% and 57.0%, respectively, in the LNR<10% group, and 11.8% and 0% in the LNR≥10% group; the difference was statistically significant (p<0.001). The 3-year and 5-year RFS rates were 52.6% and 44.6%, respectively, in the LNR<10% group, and 0% and 0% in the LNR>10% group; the difference was also statistically significant (p<0.001). When comparing the sites of first relapse, the incidence of distant lymph node metastasis in the LNR>10% group was significantly higher than that in the LNR<10% group. The LNR was a risk factor for both OS and RFS in patients who underwent curative surgery for esophageal cancer.

Postoperative hemodynamic changes for predicting anastomotic leakage after esophagectomy in patients with esophageal cancer using the FloTrac system.

Background : Anastomotic leakage after esophagectomy is significantly associated with more severe complications, such as sepsis and mortality. Early prediction for anastomotic leakage is usually difficult and needs to be treated rapidly. In the current study, we investigated the correlation between hemodynamic and several complications after esophagectomy in patients with esophageal cancer, using the FloTrac system. Materials and Methods : Between April 2013 and December 2014, 39 patients with a mean age of 66.6 ± 8.9 years underwent postoperative supervision using the FloTrac sensor / Vigileo monitoring system after curative surgery for esophageal cancer. We retrospectively evaluated the association between the number of aberrant cardiac index (CI) along with stroke volume variability (SVV) values and clinicopathological parameters of postoperative complications in this report. Results : There were significant positive correlations between the number of aberrant values of CI along with SVV and depth of invasion during pathological stage. Concerning major postoperative complications, there was a significant positive correlation between the number of aberrant values of CI and anastomotic leakage. Discussion: The hemodynamic change by employing the FloTrac system could predicts the complication of anastomotic leakage after esophagectomy. Adequate management of hemodynamic stability by utilizing it will reduce the complications of anastomotic leakage. J. Med. Invest. 67 : 240-245, August, 2020.

The Number of Harvested LNs Is an Independent Prognostic Factor in Lymph Node Metastasis-negative Patients Who Received Curative Esophagectomy

The aim of the present study was to evaluate the optimal number of harvested LNs (LNs) in patients who were LN metastasis-negative after curative esophagectomy for esophageal cancer. Sixty-one patients who underwent curative surgery for esophageal cancer between 2005 and 2017 and diagnosed as lymph node metastasis-negative were included in this study. The 5-year overall survival rates were 27.8% for 0-20 harvested LNs, 35.7% for 21-30 harvested LNs, 79.4% for 31-40 harvested LNs, and 85.2% for ≥41 harvested LNs. Thirty harvested LNs was regarded as the optimal critical point of classification, considering the 5-year OS rate. The number of harvested LNs was selected as a significant prognostic factor in both univariate and multivariate analyses. The respective 3- and 5-year OS rates were 50.3% and 36.7% for <30 harvested LNs and 82.4% and 82.4% for ≥30 harvested LNs (p=0.003). Thirty or more harvested LNs was a significant prognostic factor in patients with metastasis-negative LNs after curative esophagectomy for esophageal cancer. Therefore, the number of harvested LNs might be useful for predicting the LN metastasis status in esophageal cancer.

Clinical Influence of Anastomotic Leakage on Esophageal Cancer Survival and Recurrence.

We investigated the clinical influence of anastomotic leak (AL) on esophageal cancer survival and recurrence after curative surgery. This study included 122 patients who underwent curative surgery for esophageal cancer between 2008 and 2018. The patients were classified into those with AL and those without. The risk factors for overall (OS) and recurrence-free (RFS) survival were identified. AL was found in 44 out of the 122 patients (36.1%). The respective OS rates at 3 and 5 years after surgery were 43.9% and 40.2% in the AL group and 63.9% and 53.2% in the non-AL group, which were significantly different (p=0.0049). In contrast, the respective RFS rates at 3 and 5 years after surgery were 44.8% and 29.8%, and 44.9% and 42.4%, which were not significantly different (p=0.2306). A multivariate analysis showed that AL was a significant independent risk factor for both poorer OS and RFS in patients who underwent curative surgery for esophageal cancer. To improve survival of patients with esophageal cancer, the surgical procedure, perioperative care and surgical strategy must be carefully planned in order to prevent AL.

Influence of Postoperative Pneumonia on Esophageal Cancer Survival and Recurrence.

Postoperative pneumonia after esophageal cancer can lead to additional pain, prolonged hospital stay, and respiratory failure. These adverse events might lead to early recurrence and/or death. We investigated the influence of postoperative pneumonia on the esophageal cancer survival and recurrence after curative surgery. This study included 122 patients who underwent curative surgery for esophageal cancer between 2008 and 2018. The patients were classified into: i) those with postoperative pneumonia (pneumonia group) and ii) those without postoperative pneumonia (non-pneumonia group). The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified. The rate of postoperative pneumonia was measured by the revised Uniform Pneumonia Score. Postoperative complications were found in 34 of the 122 patients (27.9%). The OS rate at 5 years following surgery was 28.2% in the pneumonia group and 55.1% in the non-pneumonia group (p=0.006). The RFS rate at 5 years after surgery was 18.9% in the pneumonia group and 49.2% in the non-pneumonia group (p=0.061). A multivariate analysis showed that postoperative pneumonia was a significant independent risk factor for OS. The development of postoperative pneumonia was a risk factor for a decreased overall survival in patients who underwent curative surgery for esophageal cancer. The surgical procedure, perioperative care and surgical strategy should be carefully planned in order to avoid postoperative pneumonia.

RA03.02: ACUTE KIDNEY INJURY AFTER ESOPHAGEAL CANCER SURGERY: INCIDENCE, RISK FACTORS, AND IMPACT ON ONCOLOGIC OUTCOMES

Abstract Background Surgery remains the cornerstone of treatment for esophageal cancer. Esophagectomy serves as an exemplar of major operative trauma, yet there is a paucity of literature regarding postoperative renal outcomes. We aimed to study the incidence of acute kidney injury (AKI) after esophageal cancer surgery, and to determine independent risk factors for postoperative renal impairment. Methods Consecutive patients undergoing potentially curative surgery for esophageal cancer from 2006–2016 were studied. AKI was defined according to AKIN criteria. Complications were recorded prospectively and comprehensive complications index (CCI) was determined. Multivariate linear and logistic regression were performed to determine factors independently predictive of postoperative AKI. Results 661 patients (72.9% male), a mean age of 63.5 ± 9.7 years, underwent surgery (2-stage esophagectomy, 307 [46.4%]; 3-stage esophagectomy, 117 [17.7%]; transhiatal esophagectomy, 112 [16.9%]; extended total gastrectomy, 122 [18.5%)], pharyngolaryngoesophagectomy, 3 [0.5%]), with a CCI of 21.3 ± 19.7 and an in-hospital mortality of 1.4%. Baseline prevalence of chronic kidney disease was 1.8%. Postoperative AKI occurred in 174 (26.3%) patients, with AKIN 1, 2 and 3 in 122 (18.5%), 41 (6.2%) and 11 (1.7%), respectively. Of these, 5 (2.9%) required renal replacement therapy during admission. Preoperatively, greater BMI (P = 0.02, OR 1.05 [95% CI 1.01–1.10]), male sex (P = 0.05, OR 1.68 [1.01–2.78]), age (P = 0.001, OR 1.04 [1.02–1.07]), hypertension (P = 0.005, OR 1.85 [1.20–2.84]), and transthoracic approach (P = 0.01, OR 1.82 [1.14–2.89]) independently predicted postoperative AKI. After surgery, while CCI was predictive of AKI on univariable analysis (P &lt; 0.001 OR 1.03 [1.02–1.04]), atrial fibrillation (P = 0.001 OR 3.25 [1.57–6.72]) and prolonged intubation (P = 0.016 OR 3.61 [1.28–10.21]) were independently associated with AKI on multivariable logistic regression. On multivariable linear regression, neoadjuvant treatment (surgery only, 13.5 ± 35.8%; chemotherapy, 25.3 ± 42.2%; chemoradiation 18.7 ± 31.9%, P = 0.02), transthoracic approach (P = 0.006), and baseline BMI (P = 0.02) predicted postoperative %Δcreatinine. Postoperative AKI did not impact survival outcome on univariable or multivariable analysis. Conclusion Major AKI is rare after esophageal cancer surgery, with risk independently associated with increasing age, features of the metabolic syndrome, and postoperative morbidity. Disclosure All authors have declared no conflicts of interest.

Do We Need to Add Postoperative Radiotherapy in Patients Undergoing Trimodality Therapy for Esophageal Squamous Cell Carcinoma with Positive Lymph Nodes Disease?

Background: The role of adjuvant radiotherapy for positive lymph nodes (LN) in patients with esophageal cancer who received neoadjuvant concurrent chemoradiotherapy (CCRT) is not well established. This study is aimed at determining the impact of positive LN and the survival benefit of postoperative radiotherapy (PORT) after CCRT plus surgery on esophageal cancer patients. Methods: Seventy patients with positive LN after neoadjuvant CCRT followed by esophagectomy were enrolled in the study. Patients were grouped into surgery alone following neoadjuvant CCRT (n = 41) and surgery plus PORT following neoadjuvant CCRT (n = 29) groups. The preoperative radiation dose was 36-45 Gy (mean 40 Gy) and the postoperative radiation dose was 20 Gy in 10 fractions. Results: The 5-year survival rate and mean survival was 40% and 58.6 ± 53.9 months for patients with a pathologic complete response (pCR) compared with 8.3% and 22.7 ± 35.5 months, respectively, for non-pCR patients (p = 0.026). Local and distant recurrent patterns were similar for patients who did and did not receive PORT (p = 0.876). The mean survival did not differ significantly between the 2 groups (p = 0.889). Pathological complete response to CCRT was the only significant factor influencing survival (p = 0.026). Conclusions: Postoperative RT did not improve survival in patients with positive LN after CCRT followed by curative surgery for esophageal cancer.

Gastrointestinal perforation during neoadjuvant chemotherapy with cisplatin and 5-fluorouracil in patients with esophageal cancer: a report of two cases

Neoadjuvant chemotherapy (NAC) followed by surgery is the standard treatment for esophageal squamous cell carcinoma diagnosed as clinical stage II/III in Japan, and the indications for chemotherapy for esophageal cancer are increasing. Here, we report two patients who suffered from upper gastrointestinal perforation during NAC for esophageal cancer. NAC with cisplatin and 5-fluorouracil (CF regimen) was performed for both patients. Emergency operations were performed in all the patients prior to curative surgery for esophageal cancer. Endoscopic examination should be performed to confirm peptic ulcers or scars before NAC with CF regimen, and premedication with a proton pump inhibitor and the avoidance of steroid use are recommended for patients with a history of peptic ulcer to prevent perforation during NAC. Whether the occurrence of perforations during NAC is a risk factor for recurrence or a poor prognosis should be investigated in patients with esophageal cancer.

Esophagectomy in Elderly Patients With Esophageal Cancer

The number of elderly patients who undergo surgery for esophageal cancer is increasing as a result of longer life expectancy, but little is known about the morbidity and outcome of such procedures in the elderly. This study compared the results of surgery for evaluating the effect of age on esophageal cancer patients. Patients who underwent surgery with curative intent for esophageal cancer from January 1999 to July 2009 were included in this retrospective study. Data were compared between patients ≥70 years (elderly group) and patients <70 years old (younger group). Patient characteristics, hospital course, surgical mortality, morbidity, and survival were compared between patients in these two age groups. Of the 166 patients included, 35 (21.1%) were at least 70 years old (mean age, 75.2 years) and 131 (78.9%) were younger than 70 years old (mean age, 51.8 years). All 29 eligible elderly and 29 randomly selected, age-adjusted younger patients were included for a balanced comparison. The elderly group had significantly longer hospital stays (46 vs. 22 days) and a significantly higher incidence of surgical morbidity (51.7% vs. 20.7%). Cardiopulmonary-related complications were the main causes of operative morbidity in the elderly group. The elderly group also had higher performance state scores. On the basis of less adjuvant anticancer treatment received, the overall survival of elderly patients was comparable to their younger counterparts (12.1 vs. 12.7 months; p = 0.77). The results of this study suggest that curative surgery for esophageal cancer in elderly patients may result in comparable overall survival and greater, but acceptable, morbidity in comparison with younger patients. Our data suggest that age ≥70 years old should not be considered a counterindicator for curative surgery in esophageal cancer patients.