Esophagectomy In Cancer Patients Research Articles

391. MINIMALLY INVASIVE ESOPHAGECTOMY IN PRONE POSITION. INITIAL EXPERIENCE OF NATIONAL CANCER INSTITUTE MEXICO

Abstract Transthoracic approach in esophageal cancer increases oncologic outcomes but open surgery associates with poor respiratory outcomes. Minimally invasive thoracoscopic (MIT) has been selected for minimizing postoperative complications and faster recovery. It is thought that long term outcomes are equivalent to open surgery. Prone position (PP) is becoming more world important because it reduces respiratory complications and blood loss. It provides a clean surgical field and allows more lymph node harvests due to the better exposure. Observing the benefits of PP to perform esophagectomy in cancer patients, we obtained pre-certification in Japan and started in 2017. This is a retrospective study in patients with esophageal cancer operated from January 2017 to December 2021 in the National Cancer Institute. We used AJCC 8th to clinical stage; early stage was operated and locally advanced stage did neoadjuvant treatment and surgery. Our surgical results show complications and mortality on postoperative day 60 (Clavien-Dindo and ECCG classification) and short oncological results in PP-MIT esophagectomy. There were 25 PP-MITesophagectomies, median age was 57 y.o. and 84% were men. The general characteristics are indicated in image 1. The main clinical stages were locally advanced in 96% (CS III and IVA), all received neoadjuvant therapy (80% QT/RT) with a partial response of 76%. The major complications (Clavien >3) were 12% and one patient died of arrhythmia on the 10th day. Complications were classified by using the ECCG classification, are shown in image 1. The pathological results are in image 1. The mean survival was 32.1 (24.8–39.5) months and cancer specific survival was 76%. Esophagectomy has a high risk of complications and mortality and is one of the most complex surgeries in the digestive tract. In our cancer institute, we separated surgical groups to place experts in each area. Our initial experience of PP-MIT esophagectomy was a good oncological control with low complications, despite advanced cancer with poor prognosis requiring multimodal treatment.

94: HEALTH RELATED QUALITY OF LIFE OF PATIENTS WITH ESOPHAGEAL CANCER FOLLOWING ESOPHAGECTOMY TREATED WITH NEOADJUVANT CHEMORADIOTHERAPY OR CHEMOTHERAPY: A EUROPEAN MULTICENTER STUDY

Abstract Background and aim Curative treatment for patients with esophageal cancer consists of neoadjuvant treatment followed by an esophagectomy. Different neoadjuvant strategies exist; perioperative chemotherapy (pCT) and neoadjuvant chemoradiotherapy (nCRT). Both strategies improve the 5-year overall survival rate, however, whether differences exist in long-term health related Quality of Life (HR-QoL) has not been studied. The aim of this study is to compare HR-QoL between perioperative chemotherapy and neoadjuvant chemoradiotherapy in esophagectomy for cancer patients. Methods Disease-free patients following esophagectomy for cancer in one of the participating LASER study centers between 2010 and 2016, following neoadjuvant treatment with chemoradiotherapy or chemotherapy, were extracted for analysis from the LASER study database. Included patients completed the LASER, EORTC-QLQ-C30 and QLQ-OG25 questionnaires at least one year following surgery. Primary outcome was to assess long-term HR-QoL between patients treated with pCT or nCRT, using univariable and multivariable logistic regression analysis. Results Among the 565 included patients, 349 (61.8%) received neoadjuvant chemoradiotherapy, and 216 (38.2%) patient were perioperatively treated with chemotherapy. The mean age was 63.7 years (± SD 8.6) with a mean time since surgery of 4.3 (± 1.7) years. After multivariable analysis patients treated with pCT reported worse outcomes on the ‘Social Functioning’ domain (∆means 4.56 P-value<0.05) and more symptomatology on the domains ‘Insomnia’ (∆means 5.65 P-value<0.05) and ‘Diarrhea’ (∆means 5.93 P-value<0.05) of the QLQ-C30, and more symptomatology on the domains ‘Reflux’ (∆means 7.40 P-value<0.05), ‘Odynophagia’(∆means 4.66 P-value<0.05) and ‘Pain and discomfort’(∆means 4.34 P-value<0.05) of the QLQ-OG25. No statistically significant differences were observed for the LASER key symptoms. None of the observed differences in mean scores of HR-QoL domains were clinically relevant (∆means≠ ≥ 10 points). Conclusion Some differences in favor of nCRT were observed in long-term HR-QoL domains for patients following esophagectomy for cancer. However, none of the observed differences was clinically relevant (∆means≠ ≥ 10 points). HR-QoL is unhelpful when deciding on neoadjuvant strategy.

Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint.

ObjectiveThis review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint.BackgroundEsophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients.MethodsWe searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports.ConclusionsPre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.

309 ASSOCIATION BETWEEN CERVICAL ANASTOMOSIS METHODS AND ANASTOMOSIS STRICTURE AFTER ESOPHAGECTOMY FOR CANCER

Abstract Esophagectomy with three-field lymph node dissection is the most important part of advanced esophageal cancer therapy, especially for squamous cell carcinoma (SCC) patients. After esophagectomy, cervical anastomosis with gastric tube is required. However, some patients suffer anastomotic stenosis and require endoscopic balloon dilations. In this study, we investigated the relationship between cervical anastomosis methods and anastomosis stricture after esophagectomy for cancer patients. Methods Patients with esophageal cancer undergoing radical esophagectomy with cervical anastomosis were identified from the prospectively maintained database at our institution. From 2013 to 2019, 28 patients received esophagectomy with cervical lymph node dissection in our institution. Association between anastomotic methods, linear stapler vs circular stapler, and other factors (patient characteristics, surgical complications including anastomotic stenosis, and length of postoperative stay) were analyzed. Results Their average age was 63.3 years. Males and SCC cases predominated. Thirteen patients (46%) received cervical anastomosis with the circular stapler (Group C), and 11 patients (39%) received treatment with the linear stapler (Group L). None of the following variables were significant different between the two methods: preoperative chemotherapy (53.8% in group C vs. 45.5% in group L; p = 0.58), length of hospital stay (25.8 vs. 20.7 days; p = 0.15), pulmonary complications (16.7% vs. 0.0%; p = 0.36), and anastomotic leakage (33.3% vs. 9.1%; p = 0.24). However, the rate of anastomotic stenosis without malignancies was significantly higher in group C patients (66.7% vs. 0%, p < 0.01). Conclusion Cervical anastomosis with the linear stapler may be safer and associated with a lower stenosis rate than with the circular stapler. In future, cervical anastomosis with linear stapler after mediastinoscopic esophagectomy would be better for not only esophageal SCC patients but also esophagogastric junction adenocarcinoma patients with pulmonary complications.

Home enteral nutrition after esophagectomy for esophageal cancer

Not only has the placement rate of enteral feeding tubes during operations for esophageal cancer increased, but also has number of patients who choose to continue enteral feeding at home instead of removing the feeding tube at discharge. The impacts of home enteral nutrition (HEN) after esophagectomy in esophageal cancer patients are analyzed. A systematic review was conducted in accordance with PRISMA and Cochrane guidelines. English and Chinese databases, including PubMed, Embase, Web of Science, The Cochrane Library, Scopus, CBM, CNKI, and Wan Fang were searched from inception to December 7, 2019. Randomized controlled trials evaluating the short-term outcomes of HEN following esophagectomy in cancer patients were included. The risk of bias of the included studies was appraised according to the Cochrane risk of bias tool. The summary of relative risk/weighted mean difference (WMD) estimates and corresponding 95% confidence interval (95% CI) were calculated using fixed- and random-effects models. Nine randomized controlled trials involving 757 patients were included in the meta-analysis. Compared with oral diet, HEN was associated with significantly increased body weight (WMD 3 kg, 95% CI 2.36-3.63, P < .001), body mass index (WMD 0.97 kg/m, 95% CI 0.74-1.21, P < .001), albumin (WMD 3.43 g/L, 95% CI 2.35-4.52, P < .001), hemoglobin (WMD 7.23 g/L, 95% CI 5.87-8.59, P < .001), and total protein (WMD 5.13 g/L, 95% CI 3.7-6.56, P < .001). No significant differences were observed in prealbumin and gastrointestinal adverse reactions. Physical (WMD 8.82, 95% CI 6.69-10.95, P < .001) and role function (WMD 12.23, 95% CI 2.72-21.74, P = .01) were also significantly better in the HEN group. The nausea/vomiting (WMD -5.43, 95% CI -8.29 to -2.57, P = .002) and fatigue symptoms (WMD -11.76, 95% CI -16.21 to -7.32, P < .001) were significantly reduced. Appetite loss (WMD -8.48, 95% CI -14.27 to -4.88, P = .001), diarrhea (WMD -3.9, 95% CI -7.37 to -0.43, P = .03), and sleep disturbance (WMD -7.64, 95% CI -12.79 to -2.5, P = .004) in the HEN group were also significantly less than the control group. HEN improved nutrition status, physical and role function, and reduced nausea/vomiting, fatigue, appetite loss, diarrhea, and sleep disturbance compared with an oral diet in esophageal cancer patients postsurgery. HEN did not increase adverse reactions.

Colon Interposition for Esophageal Reconstruction in Cancer Patients

Objective: The aim of this study was to report our experience with colon interposition (COI) and to compare the results with an extensive review of the COI literature. Summary of Background Data: The stomach is the first choice as an esophageal substitute following esophagectomy in cancer patients, while COI is reserved for patients where the stomach is not available or must be included in the resection due to cancer. Methods: We retrospectively reviewed the records of cancer patients undergoing colon interposition from 2006 to 2017. Outcomes were compared with an extensive review of the literature published between 2000 and 2017. Results: A total of 13 patients underwent planned COI. Mortality was zero and overall morbidity was 53%; 4 patients suffered from leakage and 2 patients from strictures. None of the patients suffered from necrosis of the interponat and there was no need for subsequent redundancy operations. The extensive review identified 23 publications. Overall study grading was low (grade C). Only 3 studies were prospective, no randomized studies were found, and many outcomes were poorly defined. The rates for 30-day and in-hospital mortality were 1% and 2%, respectively. Overall morbidity was 43%. The reported number of leakages, strictures, necrosis of the interponat, and redundancy operations varied between 0% and 50%, 0% and 21%, 0% and 9%, and 0% and 2%, respectively. Conclusions: COI is a complex technique that is necessary in a relatively small group of selected patients after esophagectomy for cancer. Prospective and comparative studies with strict outcome definitions, long-term follow up, and patient reported outcome measures are lacking.

Assessment of a predictive score for pulmonary complications in cancer patients after esophagectomy.

Esophagectomy is a very important method for the treatment of resectable esophageal cancer, which carries a high rate of morbidity and mortality. This study was undertaken to assess the predictive score proposed by Ferguson et al for pulmonary complications after esophagectomy for patients with cancer. The data of patients who admitted to the intensive care unit after transthoracic esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between September 2008 and October 2010 were retrospectively reviewed. Two hundred and seventeen patients were analyzed and 129 (59.4%) of them had postoperative pulmonary complications. Risk scores varied from 0 to 12 in all patients. The risk scores of patients with postoperative pulmonary complications were higher than those of patients without postoperative pulmonary complications (7.27±2.50 vs. 6.82±2.67; P=0.203). There was no significant difference in the incidence of postoperative pulmonary complications as well as in the increase of risk scores (χ (2)=5.477, P=0.242). The area under the curve of predictive score was 0.539±0.040 (95%CI 0.461 to 0.618; P=0.324) in predicting the risk of pulmonary complications in patients after esophagectomy. In this study, the predictive power of the risk score proposed by Ferguson et al was poor in discriminating whether there were postoperative pulmonary complications after esophagectomy for cancer patients.

Factors Relating to Quality of Life After Esophagectomy for Cancer Patients in Taiwan

Little is known regarding the short-term quality of life (QoL) and predictive factors for QoL after esophagectomy for cancer in Eastern countries. The aims of this study were to assess QoL and symptoms within 1 and 6 months after surgery for esophageal cancer (EC) and to identify factors predictive of QoL within 6 months after esophagectomy in Taiwan. A longitudinal, prospective design was used, where convenience samples of 99 patients who had undergone esophagectomy for cancer were recruited from 2 medical centers in northern Taiwan. All participants responded to a questionnaire with a QLQ-C30 (Quality of Life Questionnaire-Cancer) core and a QLQ-OES18 (esophageal module of the European Organization for Research and Treatment [EORTC] QLQ-C30) module in structured interviews at baseline and 1 and 6 months after surgery. The results showed significant decline in social function and global QoL; fatigue, insomnia, eating problems, reflux, and dry mouth were major problems within 6 months. Body mass index, body weight loss before surgery, activity performance status, and anastomosis site showed no significant association with the function and symptom aspect of QoL. Surgical complications, advanced cancer, neoadjuvant therapy before surgery, and tumor location other than at the EC junction had significant deleterious effects on several aspects of QoL. This study describes the demographics of EC and short-term changes in QoL and also the predictive impact factor for QoL after surgery for EC. Knowledge of risk factors for poor postoperative QoL would be useful for health providers in detecting and prioritizing problems and treatment options in a busy clinical site.

Decreased expression of stem cell factor in esophageal and gastric mucosa after esophagogastric anastomosis for cancer: potential relevance to motility.

Esophageal replacement with gastric tube is a well-established reconstruction of the alimentary tract after esophagectomy in cancer patients. The resulting molecular events in the transposed gastric tube and residual esophagus have yet to be investigated. Stem cell factor (SCF) was recently shown to be critical for signaling in gastrointestinal motility. SCF expression is here correlated with changes in mucosal morphology, acid and biliary reflux, and motility in the residual esophagus and gastric tube. Thirteen patients surgically resected for squamous esophageal carcinoma with gastric tube replaced by esophagogastric anastomosis underwent upper endoscopy, esophageal manometry, 24-hour pH monitoring, and bile reflux detection. Esophageal and gastric mucosa samples were examined for SCF expression by immunohistochemical and semiquantitative reverse transcriptase-polymerase chain reaction analysis and for SCF serum levels by enzyme-linked immunosorbent assay. All patients showed severe residual esophagus hypoperistalsis and no gastric tube motor activity. The 24-hour pH monitoring was positive in most; 24-hour bile detection was mostly negative. SCF levels in the residual esophageal and gastric tube mucosa were dramatically decreased compared with those of normal subjects. The correlation between SCF and slow-wave activity was positive. Hypomotility of the residual esophagus and gastric tube seems closely associated with disruption of the SCF/c-kit signaling pathway. However, the absence of notable relations between mucosal changes after chronic exposure to acid, biliary gastric content, and SCF expression indicates that this analysis cannot be considered part of endoscopic follow-up.